The Literacy Academy, LLC

1051 Post Rd. Suite 1, Darien, CT 06820

Phone: 203-656-3932

Fax: 203-662-0818

email: jmattioli@theliteracyacademy.com

Please fill out the following TLA questionnaire, or download this Student Pre-Registration Form and fax or mail it back to the info above. Thanks!

(Please Note: Completion of this form does not guarantee a place with The Literacy Academy, LLC, as we are often booked well in advance. However, it does guarantee a place on our waiting list and/or a response from a literacy specialist.)

Student's full name and date of birth
Full mailing address (street, city, state and zip code)
Home and/or cell phone
Name of student's current school
Last grade completed
Email Address:
Parent(s) or legal guardian's full name(s) & contact info
Full mailing address, if different from above (street, city, state and zip code)
Phone (as many as applicable--i.e. home, work, cell, fax)
Area(s) of interest (enrichment, test prep or homework emphasis, or college essay writing)

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