Reading and Brain Training Application

Thanks for your interest in Reading and Brain Training at Wellmont Academy. We use the Orton-Gillingham Barton Method to build new pathways in the brain, strengthening the body's natural ability to form strong neural pathways over time.

Please fill out this application and we will notify you about your next steps. Please note, a $25 non-refundable application fee is required for submission of all applications.

Student Information
Student Name*
First Last
Expected Incoming Grade Level*
Gender*
Student Lives With (check all that apply)*
- Select All
- Father
- Mother
- Stepmother
- Stepfather
- Other
- Other
Parent/Guardian Information
Main Contact Email*
Enter Email Confirm Email
Father's Name*
First Last
Father's Mobile Phone Number*
Mother's Name*
First Last
Mother's Mobile Phone Number*
Emergency Contact
Emergency Contact*
Person other than parent/legal guardian who is to be contacted in case of emergency. This person must be local and from a separate household.
First Last
Relationship*
Phone*
Desired Start Date*
MM slash DD slash YYYY
Payment agreement in advance, monthly*
We agree to pay $4400/year for 40 weeks of classes to Wellmont Academy for our child’s Brain Training, as a part of our monthly FACTS invoice. We understand that there is an annual fee of $50 payable to FACTS (one fee for enrollment and for Brain Training classes) in order to use this service for our regular Wellmont Academy payments. We also understand that at any time, for any reason, Wellmont Academy may choose to terminate our student’s enrollment in Brain Training classes.
Summer Attendance Agreement*
Brain Training is based on the consistent repetition of material, so summer attendance is also a necessity. Wellmont Academy will provide 6 weeks of summer weekly classes, which are necessary to your child’s retention of the material. Scheduling can be worked out with your teacher to maximize summer memory retention and allow for vacations.
Photo Agreement*
I agree that my student’s photo may be posted on the Wellmont Academy Facebook and Instagram sites for the purpose of celebrating accomplishment or promoting Brain Training services. I understand that their name and age will NOT be posted.
Testing and other services*
We understand that Wellmont Academy Brain Training teachers do not complete psychological evaluation diagnostic tests, nor do they participate in advocacy work. They do not attend IEP or 504 meetings.
Notice of Rights
Wellmont Academy of Tampa Bay, Inc. admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of it’s educational policies, admissions policies, scholarship and load programs and athletic and other school-administered programs.
Application Fee*
Price:
Credit Card*
Card Details
Cardholder Name
Email
This field is for validation purposes and should be left unchanged.

Reading and Brain Training Application

Student Information

Parent/Guardian Information

Emergency Contact

Notice of Rights

Step 1 of 6

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Parent/Guardian Information

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School Name	Date Started Attending	Length of Attendance in Years