Student Information Form

New Student Details:

We cannot wait to see you at Study Hall! Thank you for taking the time to complete this form thoughtfully, as we value forming trusting and safe relationships that foster success.
Student Name*

First NameLast Name
Student Photo *

Browse Files
Try to find a photo that captures their personality! Cancelof
School*
FIRST Day of School for current or upcoming school year:

MonthDayYear
Date
LAST Day of School for current or upcoming school year:

MonthDayYear
Date
School Calendar Link:
This is for our scheduling purposes. Please either link a calendar or upload a calendar document.
School Calendar File

Browse Files

Cancelof
Current Grade *
Date of Birth*
Mother/Father/Guardian Name*

First NameLast Name
Mother/Father/Guardian Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Phone Number*

Area CodePhone Number
Contact E-mail*
Contact E-mail
example@example.com
Preferred method of communication/contact:*

PhoneEmailTextOther
For future scheduling confirmations, preferred method:*

EmailTextOther
How did you hear about us?*
If applicable, who referred you?
If none, state N/A.
Food Allergies*
If none, state N/A.
Is your child allergic to any pets/dogs/reptiles?*
If none, state N/A.
Tell us about your child:*
What makes your child unique: *
What are some of your child’s favorites? (Movies, color, activities, food, etc.)*
Student Interest/Hobbies :*
Diagnoses or Areas of Concern*

DyslexiaDysgraphiaDyscalculiaADHDAutismSpeech Language ArticulationExpressive/Receptive Language DisorderExecutive Functioning DisorderWritten Expression DisorderNone of the AboveOther
Diagnosis Explanation*
Is your child aware of their diagnosis?

YesNoNo, but we plan to tell him/her.Other
Current Grades in School: how is your child performing?*
Has your child had tutoring elsewhere? Was it beneficial? If possible, please list programs used. *
What are your academic goals/hopes for your child?*
What are your social/emotional goals/hopes for your child?*
Are we able to take and share photos of your child on our social media outlets?*

YesNo
Consent to use photos/videos*

I consent to the use of my photos for educational materialsI consent to the use of my photos/videos for promotional contentI understand these photos and videos are content of my student/childI do NOT consent for photos or videos to be used.

Please list at least one emergency contact: *

	Full Name	Address	Contact Number
1
2

Testing/School Documents

Browse Files
Any psychological testing reports, IEPs, etc. Cancelof
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Student Details: