Literacy & Math Tutoring 22-23 School Year

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please Register for a Spot for the 22-23 Academic Year for 1:1 Literacy and/or Math Tutoring
Monday evenings beginning at 5:15pm, September-May
Downtown Albemarle

Email *

Student Name *

Student Rising Grade Level *

Required

Student Age (as of August 15th, 2022) *

Other:

Required

Parent's Names & Cell Numbers *

Mailing Address *

Parent's Email Address *

School Child Attended (Academic Year 21-22) *

School Planning to Attend (Academic Year 22-23) *

Allergies and/or Other Important Medical Information *

Please share anything important for us to know to support your child through a fun and enriching experience. *

Does Your Child Currently Have an IEP? (scholarship funding could be available) *

Yes

If your child has an IEP, is Your Child Homeschooled or Planning to Attend a NC Private School?

Yes

Clear selection

Please Indicate the Areas of Tutoring Need *

Reading

Writing

Math

Required

Please indicate the length of tutoring session that you prefer (1/2 hour or one hour, each week). *

1/2 hour each week

1 hour each week

Required

Tutoring Costs: Please check the boxes below to indicate your understanding of the costs for Literacy and/or Math Tutoring for the 2022-2023 academic year and and your willingness to submit payment, monthly, beginning August 1st. *

1/2 hour per week, $20/week

1 hour per week, $35/week

Required

Do you provide Pfeiffer University, Scholars Academy for the Gifted, and Dr. Laura Lowder and teaching staff, permission to take and share photos and/or video of your child's engagement in activities and/or your child's products from learning? *

Yes

How Would You Prefer to Submit Payment for Tutoring? *

Pay the full balance for the school year now; please invoice me

Pay a non-refundable application fee of $75, now and pay the balance in full prior to September 1st

Pay in monthly payments beginning August 1st

Pay in payments every two weeks beginning August 1st

I wish to be considered for a partial or full scholarship to cover tutoring costs.

Required

Release of Responsibility: Do you understand that children's activities are monitored and facilitated by Falcon STEM & Literacy Center staff so as to avoid accidents or injury and that any accident, injuries, or illness (including COVID exposures) acquired while on site and are possible risks for participants. Do you agree to hold Pfeiffer University, Scholars Academy for the Gifted, and tutoring staff harmless in the event that such may occur? *

Yes

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Scholars Academy for the Gifted & Artistically Elite.

Does this form look suspicious? Report

Forms