Summer at Scottish Rite of South Texas

Reading and Language Learning Camp

Child's Name

First

Last

Layout that children

Parent/Guardian Name

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Emergency Contact

Emergency Contact Phone

Father's Name

Mother's Name

Child's Current School

Child's Current Grade

Child's Current Age

Child's DOB

Does your child have any medical conditions that would affect his/her performance in the classroom?

Has your child attended any classes designed for children with dyslexia?