Community HELP Application Community HELP Application Application for Community HELP Students Student InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY School Year of SchoolPre-K123456789101112Check Box if Home Schooled Parent/Guradian Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number(Required)Email(Required) Parent/Guradian Name (opt) First Last Phone NumberEmail Diagnostic InformationDate of last pscyhoeducation evaluation (if applicable): MM slash DD slash YYYY Please check the diagnosis(es) you have received that makes you eligible for our services:(Required) Specific Learning Disability (dyslexia, dysgraphia, dyscalculia) Attention Deficit Hyperactivity Disorder I have not received any of the above diagnoses Please list any additional diagnoses:Please explain why you are seeking academic tutoring services (reading, writing, spelling, mathematics; please be as specific as possible).(Required)ConfirmationPlease check your preference of contact:(Required) I would like to receive a phone call regarding my application. I would like to receive an email regarding my application. Disclaimer(Required) I agree to the privacy policy.By filling out and submitting this form you are applying for academic tutoring services from the Marshall University Community H.E.L.P. Program, a fee-based, nonprofit academic support program for students with a diagnosis of ADHD and/or SLD. Community HELP Coordinator, Laura Rowden, will contact you regarding your eligibility, needs, and to schedule an intake. UntitledFirst ChoiceSecond ChoiceThird Choice