Student's Name * First Name Last Name Age * Grade * Date of Birth * MM DD YYYY School Attending * Father's Name * First Name Last Name Father's Cell Phone * (###) ### #### Mother’s Name * First Name Last Name Mother's Cell Phone * (###) ### #### Street Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Does your child have any allergies (especially food allergies) * Does your child have an IEP or an equivalent document? * YES NO If yes, will you be willing to provide a copy? YES NO Has your child had a psycho-ed evaluation done? * YES NO If yes, will you be willing to provide a copy? YES NO Does your child currently take any medications for anxiety, ADHD, etc. that may have an impact on their learning? * YES NO Is your child right-handed or left-handed? * RIGHT LEFT How would you describe your child and what are the strengths of your child? (In all areas, not just academics) * What are the weaknesses of your child? (In all areas, not just academics * In regards to academics, what are your biggest concerns for your child? * What do you hope your child will gain as a result of these tutoring sessions? * How did you hear about us? * Terms of Service I agree Thank you! Student Registration Form
