Woodcock-Johnson Registration Form
Smoky Mountain Academic Resources & Training
828-891-1330
toniowen@bellsouth.net
Desired SMART tester: ___Toni Owen____________________________________
Parent/Guardian names: _________________________________________________
Name of Homeschool:___________________________________________________
Address: _____________________________________________________________
Telephone/Cell numbers: ________________________________________________
Email: _______________________________________________________________
Child: ___________________________ Date of Birth_____________Grade_______
Child: ___________________________ Date of Birth_____________Grade_______
Child: ___________________________ Date of Birth_____________Grade_______
Child: ___________________________ Date of Birth_____________Grade_______
Child: ___________________________ Date of Birth_____________Grade_______
Test Date(s) & Time(s) _________________________________________________
Previous Tests used and Tester's Name: _____________________________________
_____________________________________________________________________
Any vision, hearing, learning disabilities, etc. Please elaborate: _________________
_____________________________________________________________________
Any adaptations needed to meet special needs? _______________________________
_____________________________________________________________________
Any special concerns? ___________________________________________________
______________________________________________________________________
Who referred you to SMART?_______________________________________________
Group Test dates are scheduled in advance. Payment in Full is due upon reservation.
Individual Test date is to be scheduled directly with desired associate.
Payment in Full is due upon reservation.
Woodcock Johnson Test of Achievement - Comprehensive Battery - $100.00
Woodcock Johnson Test of Achievement - Basic Battery - $60.00
Total Enclosed_______
Checks Payable to Toni Owen
Please return form and payment to Toni Owen, 43 Goldenwood Trail, Mills River, NC, 28759
_________________________________ __________________
Name
Date