Student Information

First Name:

Surname:

Preferred Name:

Gender:
MaleFemale

Child's Date of Birth (Day - Month - Year)

Child's Current School

Contact Information

Person Enquiring

Relationship to Student

Email

Home Number

Cell Number

Address

Address Line 1

Address Line 2

Province

City

Post Code

Parent / Guardian Information

Prefix eg Mr, Mrs, Ms

First Name

Surname

Relationship to Student

Email

Additional Information

Does your child have a current (within 2 years) Psycho Educational Assessment?
YesNo

When did you first become aware of your child´s learning barriers?

What is your child’s primary difficulty at present school

Entering Year

Entering Grade

Would you like a tour?
YesNo

I consent to a credit check
YesNo