General Info About Child

Gender *
Enter 0 for Kindergarten or JK.
Mother Tongue

General Info About Child's Parents/Guardians

Medical History

Date and results of last vision and hearing exams. Please indicate which of the following have been evaluated:

Visual Accuity

Binocular Focus, Convergence & Tracking

Visual Processing


School / Learning Experiences

Does child have difficulty in any of the following subject areas? Check all that apply:

Family Background

Brother / Sister
Brother / Sister
Brother / Sister