Registration Form
Arts Integrated Enrichment Program
Student's Name:
Birth Date
/
Month
/
Day
Year
School
Grade Level
What is your greatest concern about your student's educational progress?
If the student is having academic obstacles, at what age did the problems begin?
Has the student been tutored in any academic areas before? If so, when?
Does the student have medical issues that may occur during tutoring?
Mother's Name:
Home/Cell Number
Please enter a valid phone number.
Email:
example@example.com
Father's Name:
Home/Cell Phone:
Email:
example@example.com
I have read and agreed to the Tutor/Parent/Student Partnership Agreement
Parent Signature(s):
Session Costs Per Student
prev
next
( X )
Basic
1hour/per day for 5 days a week
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Deluxe
3 hours/per day for 5 days a week
$
375.00
Quantity
1
2
3
4
5
Unlimited (RECOMMENDED SAVINGS)
Unlimited hours/per day for 5 days a week
$
275.00
Quantity
1
2
3
4
5
Submit
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