English Speaking and Reading Class Registration Form
Contact Information
Name *
Email *
Phone Number *
Student's Name *
Student's Email *
Student's Birthday *
MM
/
DD
/
YYYY
Student's Phone number *
Student's Address
(Where will the student receive classes?)
Where will the student receive classes?
Clear selection
What day(s) and time(s) is the student available for sessions?

Please select all that apply.
10am - 12pm
1pm -3pm
3pm - 6pm
6pm - 8pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What level is the student currently reading or speaking at?
Clear selection
Describe the student's educational history.

For example: 
John Smith studied English since 1995.
He attended Dandelions preschool.
He graduated from CR Walker in 2007.
Describe the issue the student is experiencing with the English Language to the best of your ability.

For Example:
Lisa has a hard time understanding when spoken to.
She is underperforming in her classes.
She started getting poor grades in grade 4.
I understand that the hourly rate for customized tutoring sessions is $60 per hour and in order to receive a discount, I need to pay on a monthly basis.
Clear selection
Comments
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms