Student Advocacy Inquiry
Please complete the following information about parent/guardian and child
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Email
Parent/Guardian Mobile Phone
Address
Address Line 2
City
Zip
How did you hear about Launch Learning Clinic?
Friends
Family
Doctor Referral
Website
Social Media
Other
How would you prefer to be contacted?
Phone call
Text message
Email
Student
Student First Name
Student Last Name
Student Birth Date
Current grade or most recently completed
School Student is Attending
Does your child have an IEP? And/or, has your child had a private evaluation for a learning disability? Please describe, and send us a copy of any IEP or evaluation.
Please provide an overview of your concerns which have led to you seeking academic advocacy.
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