diagnosis application
community programs and services
literacy center

Parent(s) Name:
Work Phone:
Child's Name:
Address:
  City:
State:
ZIP:
E-mail:
Phone Number:
School Attending:
School Address:
City:
State:
ZIP:
Child is in
Child is
Description of Problem:
I am applying for ________.
Canisius College requires that ALL vehicles obtain a permit to park on campus, would you like a Parking Permit sent to you?
Yes No
License Plate Number (required to obtain permit):
Authorization:
I give The Literacy Center permission to diagnose/tutor my child.
I will send a check/money order within the next two week to reserve my child's spot.
I will commit the time to help my child and will make every effort to be on time and attend every session.
Click here to download a printable version of our application.