Elaine Le Sueur
elaine@giftededucationservices.co.nz
10 Landon Place, Pukekohe. Auckland 2120
Ph :239 2852  Mob : 027 825 1217

PARENT  REQUEST
Fill in the form online and EMAIL it by clicking ‘Send to Elaine’ at the bottom of the page, OR, print it out, fill it in and post it to me at 10 Landon Place, Pukekohe, Auckland 2120.

* PARENT’S NAME:

* CHILD’S NAME :

SEX:

Male Female

* AGE:

* TELEPHONE:

* EMAIL:

* PREFERRED TIME TO CONTACT:

Phone call
Individual student needs analysis /analyses
School based student seminars / workshops

Other  (Please outline your requirement if it is not listed above)

TYPE VERIFICATION IMAGE:

verification image, type it in the box

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