Enroll in our Literacy Program

Literacy Camp Intake Form

Step 1 of 6

Child's Name(Required)

First Last

Age

Date of Birth

Grade (if applicable)

School Attending (if applicable):

Preferred Pronouns (optional):

Are you a current STP patient?

Yes

How did you hear about us

Name

First Last

Relationship to Child:

Contact Number (Primary):

Contact Number (Secondary):

Email Address:(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country