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Tutoring Registration 2020 - 2021
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* Indicates required question
Student's Full Legal Name
*
Your answer
Student's Preferred Name
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's email
*
Put n/a if not applicable
Your answer
Student Phone Number
*
Put n/a if not applicable
Your answer
Name of Primary Contact Parent/Guardian
*
Your answer
Relation to student
*
Your answer
Primary Contact email
*
Your answer
Primary Contact Preferred Phone Number
*
Your answer
Primary Contact Alternative Phone Number
Your answer
Second Contact Parent/Guardian
Your answer
Second Contact Relation to student
Your answer
Second Contact email
Your answer
Second Contact Preferred Phone Number
Your answer
Second Contact Alternative Phone Number
Your answer
Home Address(es)
*
Your answer
Emergency Medical Information
Your answer
Emergency Contact if Parents are Unavailable
*
List at least one person and their phone number.
Your answer
Person(s) Responsible for Billing
*
Your answer
Billing Contact's Phone Number
*
Your answer
Email Address for Invoices
*
Your answer
Grade for School Year 2020 - 2021
*
7
8
9
10
11
12
Other:
Name of School Student is Currently Attending
*
Your answer
Subject(s) needing tutorial support.
*
Your answer
List the number of tutoring sessions per week and day/time requests.
*
Your answer
Preferred Start Date
*
MM
/
DD
/
YYYY
Teacher/Tutor Preference
List first, second, and third choices if known.
Your answer
Will student need Privett van transportation from Privett to MIHS in the morning or from MIHS to Privett in the afternoon?
*
Choose
Yes, AM transportation
Yes, PM transportation
Yes, both AM and PM transportation
No
Unsure at this time
If you answered yes to the previous question, please complete and return a transportation permission form found at the link below.
https://docs.google.com/document/d/1mhBH9wzp5-Oe68m7X2evENqoo-m9wqqKwGdDtjzjUR8/edit?usp=sharing
By submitting this form, you acknowledge that all information provided is accurate and agree to The Privett Academy's Fees & Policies.
https://www.privettacademy.org/policiesandfees.html
The following is required before a student can be scheduled and services can be provided:
*Tutoring Registration Form
*Transportation Permission Slip (for students taking the van)
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