Tutoring 2022-2023 Registration
Please complete 1 form per child.
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Email *
Student's Name *
Parent's Name *
Address, City, State, Zip *
Parent's Phone Number *
Parent's Email *
Student's Date of Birth *
MM
/
DD
/
YYYY
Grade Level *
Medical Concerns *
Emergency Contact Name and Relationship to student *
Emergency Contact Phone # *
Tutoring Subject / Needs *
Does the student have an IEP or 504 plan? *
Preferred Days and Time of tutoring *
How many times per week? *
Where would you like the services performed? *
Required
How did you hear about us? *
Other comments/concerns
Place your initials here as signature for submission of this form and acknowledgment of the P&P. *
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