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Location (circle date and place):
Lakewood: 2/7& 14, 2011 OR 4/22&29, 2011 Summit /
Tacoma – May 24-26, 2011; Elma Area – June 1 & 2, 2011; Other
Dates/Places: _________________________
Test Level
Grade
Student's Name
Birth Date
Grade
14 3.6 -
5.2 ____________________________________________________________
15 4.6 - 6.2
____________________________________________________________
16 5.6 - 7.2
____________________________________________________________
17 6.6 -
8.2 ____________________________________________________________
18
7.6 - 9.2
____________________________________________________________
19 8.6 -
10.2 ____________________________________________________________
20
9.6 - 11.2 ____________________________________________________________
21/22 10.6 -
12.9 ____________________________________________________________
NOTE: Please put an asterisk (*) by
the name of any child who has never had an achievement test before.
If your child has been diagnosed with (Attention Deficit
Disorder/Attention Deficit Hyperactive Disorder) please indicate
with an "ADD" or “ADHD by his/her name. You may also register
non-test assessments on this paper. Give same information regarding
the child and mark –NTA and add the appropriate amount: $60.00.
Payment:
Levels
14-21 Number of students to be tested ______x $40.00
(Individual and small group testing ______ x $50.00) =
Subtotal of Testing
Fees
10%
Discount for three or more children tested Subtotal:
________ x 0.9 =
Scoring done by
administrator – ADD Number of students _________ x
$15.00 =
Total (Enclosed)
Please make checks payable to Ronnie Dail
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For
your convenience, we accept all major credit cards.
For
online payment: http://www.centerforneurodevelopment.com/category/33984720
Refunds for cancellations will be given up to 14 days prior to the
first day of testing.
You
may reschedule with at least One - Week Advance Notice.
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