HEART OF LEARNING TUTORING SERVICES INTAKE & REGISTRATION FORM
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Email *
Why should you sign your child up for tutoring?
Child’s Name *
Student's Current Grade: *
Student's D.O.B. *
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Student's Current School? *
Area or Subjects of Concern? *
Student's most recent standardized test results? (Indicate pass/fail or "NA" if you do not have their scores.) *
Does your child have any diagnosed learning differences? *
If you answered yes to the question above, what are they? If no, do you suspect that your child has a learning difference and if so, what? (Your response helps us to best match your child with  an Academic Coach who is knowledgeable and experienced to meet your child's needs.) *
Do you have any concerns about how your child is learning/progressing academically? (Behind their classmates, does not seem to be improving, struggles, etc.) *
What is your child's favorite subject in school? *
What does your child enjoy doing when not in school? *
Does your child play sports, an instrument, or any other extracurricular activities? *
Parent or Guardian's Name? *
Phone # for Parent or Guardian? *
Is it okay to send text messages including appointment reminders, updates or special offers to the number listed above? *
Please provide your child's email address if they have one.
What subjects, concepts or skills would you like for your child to receive tutoring or academic support? *
During the school year, would you want your child to receive homework help, or tutoring that addresses areas of need  or gaps? *
At this time, do you plan for your child to return to school or attend school online? *
If you choose for your child to attend school online, are you interested in the Heart of Learning Education Center's staff, facilitating their online learning?
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