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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? * Required

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? * Required

Monday

Tuesday

Wednesday

Thursday

Friday

What times work better for you? * Required

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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