Registration LDA Child and Youth Registration Parent/Caregiver 1* First Last Parent/Caregiver 2 First Last Parent Daytime Phone*Parent Email* Child/Youth Name* First Last Date of birth (DDMMYYYY)* MM slash DD slash YYYY What grade is the child/youth in?* Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Which session(s) are you registering for?*Academic Skills ProgramReading & WritingB.C. Wide Online Reading ProgramEmotional Social DevelopmentHas the applicant been assessed or diagnosed with any of the following?* LD AD(H)D Anxiety Disorder Other None If you selected "Other" for the above question, please specify what the applicant has been assessed/diagnosed with:Does your child struggle in school?* Yes No Do you have any concern about your child's learning or behavior development?* Yes No Do you have any concern about your child's learning or behavior development?* Yes No If so, please describe your concernsIf available, do you require financial assistance?* Yes No Would you prefer in-person or virtual (if available)* In-person Virtual CAPTCHANameThis field is for validation purposes and should be left unchanged.
