Orton-Gillingham Registration Form

Date of Birth *

Month

Day

Year

Last Name *

First Name *

Middle Initial

Address

Number and Street *

City *

State *

Zip Code *

E-mail Address *

Cell Phone *

Alt Phone

Do you receive tuition benefits? *

Yes

Employer Name *

Course 1

Term *

Course Number *

Note: Discontinuation of class attendance or notice to an instructor does not constitute authorized withdrawal. If you stop attending class and do not notify the Registrar’s Office, you will receive a grade of “F” and be liable for all tuition charges.

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Orton-Gillingham Registration Form