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NEW STUDENT QUESTIONNAIRE

Please take a moment to fill out the form.
(Your information will be kept private)

Parent/Guardian Information

First Name

Phone

Last Name

Email

How did you find us?

Google

Instagram

Facebook

Friend/Family Referral

Other

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Student Information

Student's Full Name

Student's Date of Birth

Student's Grade Level

What method have you chosen to educate your child(ren)? *

Public School

Private School

Homeschooling

Other

What subject(s) are you interested in for tutoring?

Reading

Writing

Math

Other

Has your child received tutoring before? *

Yes

No

If yes, how was your experience with the previous tutor?

What days work better for tutoring?

Monday

Tuesday

Wednesday

Thursday

Friday

What times work better for you?

Late afternoon (3-6pm}

Early evening (6-8pm)

How many sessions per week are you looking for? *

One

Two

Other

Does your child receive any additional services from school? Does he/she have an IEP or 504 accommodations?

What is the main thing you are hoping your child will accomplish through tutoring?

Do you have any other information/ questions you would like to share with us?

Thanks for submitting!

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