Fillable A RS HI P A P PL I (Mississippi)

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A RS HI P A P PL I (Mississippi)

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The A RS HI P A P PL I (Mississippi) form is 1 page long and contains:

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  • 2 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

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New Applicant
Returning Student
Dyslexia Therapy Program
S CHOL
A RS HI P A P PL I CA T I ON
2022-2023 School Year
STUDENT INFORMATION
Student Full Name
Student Full Address
Student DOB
MSIS ID
Entering Grade (2022-2023)
Parent Full Name
Parent E-Mail Address
Phone
PREVIOUS SCHOOL INFORMATION
The information provided should reflect where the student has been in attendance for the 2021-2022 School Year.
District
School
Enrollment Date
Withdrawal Date
PROSPECTIVE SCHOOL INFORMATION
Information provided should reflect where the student will be in attendance for the 2022-2023 School Year.
PUBLIC
SCHOOL
District Name
Public School Name
Public School Phone
Enrollment Date
SPECIAL PURPOSE
NON-PUBLIC
SCHOOL
3D School, Petal
School Phone
Enrollment Date
Required Documentation Must be Attached to this Application
The student has received an evaluation and has a diagnosis of dyslexia determined by
a licensed psychometrist, psychologist, or speech language pathologist as specified in
Miss. Code § 37-173-15.
Yes No
Documentation of Acceptance and Enrollment into new school is provided.
Yes No
I do hereby certify that all information provided by me in this application and the attached documents are true and correct to
the best of my knowledge. I further understand that in the event I have knowingly and willfully made any false statements, my
student will be immediately removed from the Dyslexia Therapy Scholarship program and all funds will be forfeited.
Parent/Legal Guardian Signature Date
Magnolia Speech School, Jackson
Please send the completed application and attachments (Certified Mail Return Receipt Requested) to:
Mississippi Department of Education
Office of Elementary Education and Reading
Attn: Dyslexia Scholarship
P.O. Box 771
Jackson, MS 39205
MDE Office Use Only
Date Received:___________Approved ___ Denied ___
Date Notification Sent: _______________
Reason for Denial: __________________
Lighthouse Academy, Ocean Springs
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A RS HI P A P PL I (Mississippi)

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Completed 5 April 2022

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