Enrollment Application

Date of Application*

Student Information

Student first name*

Student last name*

Grade*

Student DOB*

Gender*

Male

Female

School name*

School city, state*

Has the student ever been diagnosed with any mental health disorder?*

yes

no

If yes, please specify here

Preferred tutoring day(s) of the week*

Preferred tutoring times*

Learning Goals*

Is your child currently receiving any other academic support (e.g., in-school tutoring, after-school programs)*

yes

no

If yes, please specify here

Are there any special accommodations or considerations that we should be aware of?*

yes

no

If yes, please specify here

How did you hear about us?

Parent/Guardian Name*

Parent/Guardian Phone Number*

Parent/Guardian Email*

Do you give consent for us to photograph your student for future advertising?*

Yes, I give consent

No, I do not give consent

Signature*

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