ESA Assessment Form

First Name *

Last Name *

Phone *

Email *

Student's Information

Student's Full Legal Name (matching ESA information) *

Student's Age *

Student's Grade Level *

What is your child's current reading level? *

Is this student currently enrolled in the Arizona ESA program?

Has your child previously received educational intervention or tutoring?:

If yes, please describe (Response optional):

I understand that payment to Dyslexia Rescue® is not contingent upon Arizona ESA/ClassWallet reimbursement. Reimbursement eligibility and approval are determined by the Arizona Department of Education/ClassWallet, and Dyslexia Rescue® cannot guarantee reimbursement.

I agree to the terms & conditions provided by Dyslexia Rescue® for ESA funded services