Login
Login to your account
Username
Password
Login
About
Assessment
Programs
Results
Blog
After School
Student Intake Form
Student
First Name (Student)
Last Name (Student)
Street Address (Student)
City/Town/Village (Student)
Province (Student)
Postal Code (Student)
Date of Birth (Student)
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Year
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Prefer not to Answer
Number of Siblings (Student)
0
1
2
3
4
5+
Birth Order (Student)
1st Born
2nd Born
3rd Born
4th Born
5th+ Born
Know Allergies (Student)
Parent 1
First Name (Parent 1)
Last Name (Parent 1)
Street Address (Parent 1)
City/Town/Village (Parent 1)
Province (Parent 1)
Postal Code (Parent 1)
Cell Phone Number (Parent 1)
Home Phone Number (Parent 1)
Work Phone Number (Parent 1)
Email Address (Parent 1)
*
Parent 2
First Name (Parent 2)
Last Name (Parent 2)
Street Address (Parent 2)
City/Town/Village (Parent 2)
Province (Parent 2)
Postal Code (Parent 2)
Cell Phone Number (Parent 2)
Home Phone Number (Parent 2)
Work Phone Number (Parent 2)
Email Address (Parent 2)
*
Additional School Information
School
Grade
Primary
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Teacher's Name
Is your child currently enrolled in resource?
Yes
No
Is you child enrolled in any other programs?
Yes
No
If you answered yes to the above please list and describe the other programs below.
Has your child ever been tested for a learning difficulties?
Yes
No
If yes, when were they tested?
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Year
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
If yes, where were they tested?
Examiner Name
Medical Information
Does you child wear glasses?
Is your child on any medications?
Does your child have a physical disability?
Is your child right handed?
Is your child left handed?
Does your child have any hearing problems?
Does your child have any allergies?
Other
Does your family have a history of learning difficulties?
Yes
No
Please share your concerns regarding you child.
What are your child's interests and strengths?
How did you hear about Novaread?
Family
Friend
Phycologist
School
Internet Search
Facebook
Twitter
Instagram
Google Adwords
Other
Type the characters
*
This field should be left blank
Send
Please wait...
Automated page speed optimizations for fast site performance
