Course for Credit & Tutoring Registration Summer 2020
All sections must be filled out.
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Student's Full Legal Name *
Student's Preferred Name
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's email *
Put n/a if not applicable
Student Phone Number *
Put n/a if not applicable
Name of Primary Contact Parent/Guardian *
Relation to student *
Primary Contact email *
Primary Contact Preferred Phone Number *
Primary Contact Alternative Phone Number
Second Contact Parent/Guardian
Second Contact Relation to student
Second Contact email
Second Contact Preferred Phone Number
Second Contact Alternative Phone Number
Home Address(es) *
Emergency Medical Information
Emergency Contact if Parents are Unavailable *
List at least one person and their phone number
Person(s) Responsible for Billing *
Billing Contact's Phone Number *
Email Address for Invoices *
Grade for School Year 2020-2021 *
Name of School Student is Currently Attending *
Course(s) Interested in Taking *
**If any courses are grade replacement, please make a note of that.  If taking one semester of a year-long course, indicate which semester, first (A) or second (B). For instance, if taking grade replacement for second semester Geometry, write "Geometry B Grade Replacement" or "Geometry B GR."  If you are registering for tutoring, please write tutoring before the course subject.
Schedule Request *
Please make note of any vacations, preference of morning vs afternoon, number of days per week, etc., if known.
Teacher Preference(s)
By submitting this form, you acknowledge that all information provided is accurate and agree to The Privett Academy's Fees & Policies.
The following is required before a student can be scheduled and services can be provided:
*A non-refundable registration fee of $150 (waived for tutoring)
* Registration Form
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