Roberts Scholarship Application " Roberts Scholarship Application Parent Name First Last Student Applicant Name First Last Age of Applicant:Grade of Applicant:School Applicant is AttendingDoes student have: IEP 504 Plan Qualification Category? If yes on Qualification Category, please enter here:Has student been diagnosed with dyslexia previously?YesNoBy whom?Has student had other testing?YesNoWhat for?Has student been diagnosed for anything else?YesNoIf yes, what was the other diagnosis?Phone:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Total Family Income:Please Check ALL that apply: Are you a single mom living on a single income? Able to attend tutoring 2 times/week Willing to Share Story on Go Fund me Warning Signs of Dyslexia: Please Check all that ApplyPreschool Years: Delayed Speech Mixing up sounds & syllables in long words Chronic ear infections Severe reactions to childhood illnesses Constant confusions of left versus right Late establishing a dominant hand Difficulty learning to tie shoes Trouble memorizing their address, phone number or alphabet Can't create words that rhyme A close relative with Dyslexia Elementary School Years:Elementary School Years: Dysgraphia-slow, non-automatic handwriting-difficult to read Letter or number reversals past 1st grade Extreme difficulty learning cursive Slow, choppy, inaccurate reading Guesses based on shape or context Skips or misreads prepositions (at, to, of) Ignores suffixes (ed, ing) Can't sound out words Terrible spelling Often forgets sight words or homonyms (their, they're, there) Difficulty telling time on clock w/hands Trouble with Math Math-Can't memorize multiplication tables Math-Can't memorize a sequence of steps Math-Struggles with directionality Speaking-Can't find correct words Speaking-Lots of "whatyamacallits" and "thingies" Speaking-Common sayings come out slightly twisted Extremely messy bedroom, backpack, & desk Dreads going to school Dreads going to school-complains of stomach aches or headaches Dreads going to school-nightmares about school In High School: All of the above, Plus:In High School: All of the above, Plus: Limited vocabulary Extremely poor written expression Written expression-discrepency between verbal skills and written compositions Unable to master foreign language Difficulty reading printed music Poor grades in many classes May drop our of high school
