The House Enrollment Form
Please let us know about your children.
The Parents
Parent Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
What are you interested in?
*
Memberships
Individual Tutoring
Test Prep
PODs
When would you like to start?
*
-
Month
-
Day
Year
Date
Which location is preferred for private tutoring sessions?
*
The House tutoring Lounge (682 Vernon Ave, Glencoe, IL 60022)
In-Home (a family home)
Online/Virtual
Approximately, how many sessions would your student like per week?
*
1
2
3
4
5
6
7
Other
Your Student(s)
Tell us the kids in YOUR FAMILY
Please give us some information about the subjects your students will be learning:
*
Child 1
Child 2
Child 3
Name
School
Grade
-------
Subject 1
Subject 2
Subject 3
Subject 4
Subject 5
Subject 6
Which of the above subjects will need to be the main focus?
Please tell us about your children (personality, learning style, challenges, etc.):
Any Special Education considerations we should know about?:
Any professionals - clinicians, counselors, etc. - you might want us to connect with?:
Let us know the preferred days and times for your student's sessions - if you are unsure, give a range (morning, afternoon, evening, weekends, etc.)
*
Upload any documents you want us to review (IEPs, reports, etc.)
Browse Files
Drag and drop files here
Choose a file
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of
SUBMIT
OPTIONAL: If you're interested in forming your own POD, please continue.
Let us know who you would like to join your POD.
First Child's Name
What families would you like in this child's POD?
Family 1
Family 2
Family 3
Family 4
Family Name
Contact Person
Email
Phone Number
Number of Students
Pod Organizer (Point Person)
First Name
Last Name
Second Child's Name
What families would you like in this child's POD?
Family 1
Family 2
Family 3
Family 4
Family Name
Contact Person
Email
Phone Number
Number of Students
Pod Organizer (Point Person)
First Name
Last Name
Third Child's Name
What families would you like in this child's POD?
Family 1
Family 2
Family 3
Family 4
Family Name
Contact Person
Email
Phone Number
Number of Students
Pod Organizer (Point Person)
First Name
Last Name
How did you hear about us?
Please Select
Someone told me about you
General buzz
I walked past your location
Google
Social Media Ad
Social Media Platform
Press
TV
Referral
Other
Submit
Should be Empty: