Reading Program Inquiry Form – Harlem Literacy Project

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© 2019

Reading Program Interest Form

Contact Information:

Parent/Guardian Full Name *

Email Address *

Phone *0 / 10

City *

State/Province *

ZIP / Postal Code *

Student Information (All student information is kept strictly confidential):

Child’s Age *

Child’s Grade *

School Name *

School District *District 3District 4District 5

Program of Interest:

Which program are you interested in? *KinderPrep (Pre-K, Age 4)Harlem Reading Project (K-2)

What times are you and your child available for a virtual consultation?MorningsAfternoonsEveningsWeekends

Student Academic History :

Does your child currently receive any reading support? (e.g., tutoring, special education)

Is there anything specific you’d like us to know about your child’s literacy needs?

How Did You Hear About Us?

Agreement Checkbox:

I understand this program is invite-only and submitting this form does not guarantee enrollment. *I understand.

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