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Title

First name

Last name

Email address

Mobile number 1 **

Mobile number 2

Landline number

** Please specify at least one phone number.

Please specify a mobile phone if you’d like to receive SMS notifications.

Street address

City

County

Postcode

For statistical purposes only, please let us know which best describes you:

Same details as above

First name

Last name

Date of birth

Age

—

Gender

Male

Female

Non-binary

Prefer not to say

Please provide your main reasons for submitting this Booking Enquiry.
Please note: your Booking Enquiry will not be processed until we have received the relevant completed questionnaires (you will receive a link to these after submitting this Booking Enquiry).
If you have a question that you would like answered before completing the questionnaires, please email us [email protected].

What is your ethnic group? (NB: This information will help ensure our services meet the needs of all ethnic groups).

Service

If you need any help deciding which service you need, please contact us on [email protected]

Assessments and dyslexia support can take place in a range of venues or online, depending on the type of assessment or support required.

Postcode

Please indicate how far you would be willing to travel and whether online support would be of interest to you.

30 miles

50 miles

100 miles

online

IMPORTANT NEWS:
We regret that we are currently closed for bursary applications until further notice, due to high volume of enquiries.
The waiting-list for bursary applications will re-open when funding becomes available.
If you are from a low-income household, in receipt of means-tested state benefits or qualifying for pupil premium (free school meals) , you may register your interest, for consideration in the future. If so, please tick the box below and answer the further questions.
When our waiting-list re-opens, we will contact you.
WHEN YOU HAVE REGISTERED YOUR INTEREST, PLEASE BE PATIENT AND WAIT FOR US TO CONTACT YOU, AS OUR TEAM ARE OVERLOADED, PROCESSING EXISTING CLIENTS.
There is no guarantee that registrations of interest will be successful. We apologise for any inconvenience caused.

Would you like to register your interest in a bursary?

Yes

Our bursary programme can be used towards the cost of dyslexia assessment, consultations, specialist tuition for children/students and skills development coaching for adults. Each bursary application is carefully assessed, using the information you provide below. All bursaries are awarded on a first-come-first-served basis and are subject to the degree of need in each case, and the availability of charitable funds. Unfortunately, it is impossible for us to grant all bursary requests, due to lack of funding.

It will increase your chances of being granted a bursary if you volunteer an amount in the ‘Client Contribution’ box. We have learned from experience that people are much more likely to successfully engage with our services if they have volunteered a financial contribution of their own. Please note that payments can be made in instalments. Thank you.

I would like to apply for a bursary to help towards the cost of: (tick all that apply)

Consultation

Dyslexia Assessment

Tuition/Coaching

Who is the bursary for?

It's for me

It's for my/our child

Is your child's address and postcode different to yours?

Yes

No

Please provide the child's address and postcode

What difference will a bursary make to you?

Tell us what difference you think one or more of our services would make to your life, or to your child? How will the bursary help in this respect? Tell us about the challenges faced and what you hope will change with our help, in the context of home, education, work and leisure. If you would prefer to discuss this, rather than write it down, please feel free to contact us on 01252 792 400.

To ensure our bursaries are used for those with the greatest financial need, please explain your financial circumstances by answering the following questions as fully as possible. If not applicable, please answer with "N/A".
Please note that we may also request copies of relevant paperwork to support bursary applications:

What is your employment status? If working, please state role and hours.

What is your partner's employment status (if applicable)? If working, please state role and hours.

What are your (plus any partner's, if applicable), approximate monthly earnings?

If you are a single parent, does your ex-partner contribute to your monthly income? If so, how much?

What is your (plus any partner's, if applicable) approximate monthly expenditure?

Do you receive benefits? If so, which ones and for what amounts?

Is your child eligible for Free School Meals? (if applicable)

Why are you struggling financially and why do you think you should qualify for bursary assistance?

All information you provide will be treated in strict confidence and will be used solely for the purpose of assessing your bursary application. A link to details of our Privacy Policy can be found here or a hard copy can be provided on request at [email protected].

I am able to pay the following amount towards the session cost:

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Yes please

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