Learning Disability Assistance Documentation Form
Full Name
Date of Birth
Email Address
Phone Number
Educational Institution
Program/Course
Year/Grade
Type of Learning Disability
Dyslexia
Dyscalculia
Dysgraphia
ADHD
Other
If "Other", please specify
Documentation of Diagnosis
Diagnosing Professional (Name, Qualification, Contact)
Assistance or Accommodations Requested
Additional Information