Lamplighter Educational Resource Center
70 Cemetery Road * Milford, OH 45150 * (513) 831-6344

Parents:    Please return this form with your $18.00 registration fee. Then we will call to schedule. This information is confidential and for professional use only.
      Your child's school records will help us in our work. Please contact the school and ask that pertinent records be mailed to Dr. Vivian Franz, Consultant, Lamplighter.
Registration For: ___________________________
Student Name
 Grade: __________ Age: __________
Birthdate: ________________       Gender: M / F

 School: ______________________________
Home Address: _____________________________________________________________________
Please be sure to give the zip code.
Home Telephone: _________________________

 E-Mail (if you wish): _____________________
Mother's Name: _____________________________

 Business Telephone: ________________________
Father's Name: _____________________________
 Business Telephone: ________________________
Preferred person to contact regarding student's work here: _______________________________

Names and ages of siblings____________________________________________________________

Student's Physician: _____________________
 Telephone: __________________________
Permission by signature below is granted to call the physician above, 911, or the life squad in case of an emergency, if parents or guardians can not be reached immediately. Additional emergency information and instructions, if any, are listed here or on the back of this sheet.

Is the student on any medication? Are there special instructions for us? ________________________
Please list on the back of this page any facts you deem important for us to know relative to the student's birth history, infant development, overall health, or academic history.

This is a request for help with: _____________________________________ List academic area, subject, etc. If the student is coming for help with test preparation (PSAT, SAT, PACT, ACT, COOP, HSPT, or state proficiency examinations), when is the student taking the test or tests? ______________________

If test preparation, has the student taken the test before? _____ If so, what were the scores earned? ______
I have read the Procedures Sheet on either Single Subject Tutoring or Test Preparation given to me or taken from the website.

Date: __________________
______________________________________________________________
Parent or Guardian