ENTER YOUR INFORMATION BELOW AND SUBMIT THE FORM
1. Last Name
First Name
Middle Name
2. Street Address
City State Zip Code
Your Phone Number
Your Email Address
3. Social Security Number (If you have it)
4. Personal Data Your Date of Birth (MM/DD/YYYY)
Male Female
Your Parents
Father's Name
Mother's Name
Parents' email
Work phone No. for father
Work phone No. for mother
Occupation for father
Occupation for mother
5. Education Background
Date of Last Educational Evaluation
Name of High School
Graduation Date
Grade point average from high school
If you are planning to enter to college, what is your proposed major
Have you been diagnosed as learning disabled/ADHD?
Yes No
If yes, by whom? Give name and address
Name Address
Were you in a Learning Disabilities class in high school?
If so, please state how much time and in what areas you received help:
How much time
In what areas
Do you have problems with the following? Please check all that apply
Note-taking Reading
Study Skills Written language
Test-taking strategies Mathematics
Organizational skills ADHD/ADHD (attention span)
Difficulty with reading Other
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After completing the application please go to the application checklist to review application and tutoring fees, as well as to find out what is needed to complete your application.
The Higher Education for Learning Problems Center is a non-profit organization
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