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Single ACT Diagnostic Package

$150

Dual Diagnostic Package

$200

Enrollment Form

Student's Name(Required)

First Last

Student's School(Required)

Student's Grad Year(Required)

Does your child have an IEP, 504 or education plan in school?(Required)

Yes

No

Does your child have approved accommodations on the PSAT, SAT or AP tests?(Required)

Yes

No

Parent's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent's Email Address(Required)

Parent's Cell Phone Number(Required)

Would you like to receive a text reminder 48 hours before the assessment(s)

Yes

No

Test(s) of Interest(Required)

Preferred Method of Testing(Required)

Preferred Diagnostic Test Date(s)(Required)

In-person testing takes place in our Wayne, PA office most Saturday mornings during the school year and Wednesday mornings in July and August. Virtual testing can take place any morning(s) of your choice (7 days per week). Please select one morning per test, and share your preferred date(s), if known, above:

Preferred Method of Contact for Confirming the Test Date(s)(Required)

Student's Cell Phone Number(Required)

Would you like your child to receive a text reminder 24 hours before the assessment(s)?(Required)

Yes

No

Student's Email(Required)

Would you like your child to receive an email reminder 72 hours before the assessment(s)?(Required)

Yes

No

Who referred you to Educational Services?(Required)

Please confirm your preferred diagnostic package:(Required)

Credit Card