Building Knowledge Everyday Student Info Form

Student Registration Form

Fill out the form carefully for registration
Student Name *

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Gender *
Birth Date *

Month Day Year
Client E-mail *
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Tutoring Information
Subject Area For Which You are receiving Tutoring *
Tutoring Objectives-What is the objective of your Tutoring? (Select all that apply) *

Remedial Instruction Exam Preparation Subject Mastery Learning Study Skills
Frequency-How often would you like to meet with a tutor? *

Once a week Twice Weekly More than Twice a Week Once Every Two Weeks
If you are preparing for an upcoming standardized test (e.g. SAT), please enter the date of the upcoming exam below.
Date

Month Day Year
Comments or Concerns- Is there anything else we need to know?
If you have accurately and completely filled out this form, then please click "Submit" below. Thank you!
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Student Registration Form