For More Information To receive more information concerning services provided by Dyslexia Research Institute and/or Hardman and Associates, please fill out the following. (Some information can be e-mailed or faxed; other bulky information will have to be mailed.) I. Contact Information (* denotes optional information) Name E-mail Address Telephone Number* FAX Number* Street Address* City* State* Zip* & II. Do you want to be placed on our E-mail list to receive notices of updates to our web page? Yes No III. Demographics (Check all that apply) 1. Are you the parent of an ADD/Dyslexic child? 2. Are you the parent of an ADD/Dyslexic adult? 3. Are you an educator of ADD/Dyslexic children? 4. Are you an educator of ADD/Dyslexic adults? 5. If none of the above, what is your interest or relationship with Dyslexia/ADD? Counselor Medical Drug Rehab Corrections Disability specialist Other Please explain: IV. Send me information concerning: Diagnostic Testing     child   adult Woodland Hall Academy       Full-time school     Tutorial programs     Summer school Advocacy and Consultation   Teacher Training   Parent Seminars (Tallahassee)   Seminars (Onsite)   (This information will consist of how to access these services: costs, schedules, and content.) V. Comments Use this box to send us any comments or questions you have about ADD/ADHD or this website. While all responses will be read, we may not be able to answer each individually. We will, however, respond to representative questions in our update section.

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