Student Registration Form- Ginsburg Advanced

Student Registration Form

Due to the value of your time, our time, as well as the time of other students, we have found that a simple registration form and student contract helps to serve all of our interests. Please take the time to read through the following points before signing. Feel free to ask any questions or express any concerns that you may have.
Name *

First Name Middle Name Last Name Suffix
e-mail *
example@example.com
Primary Phone *
Please enter your mobile or primary phone
Work Phone
Enter your work number here
Cell Phone
Enter your cell phone number here
Address *

Street Address

Street Address Line 2

City State

Zip Code
Date of Birth *

Month Day Year
Emergency Contact (If a minor, include Parent/Guardian contact) *
Relationship to Student *
Emergency Phone *
Enter your emergency phone number
Billing Info
Payment Agreement *

Fees shall be calculated at a rate of $250 per 60 minute session with Shana Ginsburg, Esq. for tutoring and admissions services, $135 per 60 minute session with Premier tutors, and $109 per 60 minute session with all other Ginsburg tutors. Rates are subject to package discounts. No fees shall be charged for traveling or preparation time of the Tutor. A flat fee of $389 shall be calculated for Accommodations Assistance, which includes a 1-hour consultation with Shana Ginsburg, Esq., completion of all Accommodations forms, and instructions and guidance to the Student and Student's verifying medical or therapeutic professional on documentation and eligibility requirements. Military and LSAT Fee waiver students are eligible for 10% off the service. All payments to Ginsburg Advanced Tutoring, LLC will be made via credit card or check. Credit card information will be stored electronically following the strictest PCI guidelines. The credit card on file will be used to pay for each session at or after the time of the session. Clients may request a statement of billing history at any time, for no additional fee. Invoices will be delivered via email. The Student may cancel a session by giving at least 24 hours prior notice in which case no session fees will be incurred. Sessions that are not attended for any reason by the Student, without giving 24 hours notice prior to the start of the session, shall be charged up to 50% for the first cancellation, and up to 100% for any cancellation thereafter.
Billing Name *

First Name Last Name
e-mail *
example@example.com
Primary Phone Number *
Enter your primary phone number
Cell Phone Number
Enter your cell phone number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student Education & Testing History

Most of our students have tried traditional test preparation programs or have self-studied before working with us. Tell us a little about your journey to date, and we'll design your curriculum to advance you from wherever you are in your test preparation process.
New or Returning Student? *

Returning Student New Student
I am interested in the following Ginsburg Advanced Tutoring services:

Tutoring Accommodations Assistance Admissions Assistance
Tutoring Subject
Select one subject
Instructor Preference
Select one
Tutoring Time Preference
Select one
What have you already done to prepare for your exam? *
Have you ever been diagnosed with a learning disability, psychiatric disorder, or learning difficulty that impacts your academic performance? If so, please describe the diagnosis, symptoms, and provide the date you were first diagnosed.
High School & High School GPA
College & College GPA *
Did you receive accommodations for testing while in high school or college? If Yes, please describe.
What were your scores and test experiences on prior standardized tests?
What is your highest practice score or official score to date? (If applicable)
What is your goal score for your exam?
What is your dream school? Target school? Safety school?
Test Anxiety Diagnostic

Some anxiety is normal- it protects your body from physical threat. But when you experience too much anxiety, it can lead to emotional or physical distress on test day, and students with the highest test anxiety can perform 12% lower than their low-anxiety peers. Look at the list below and select any of the symptoms of test anxiety you experience when taking or preparing to take a standardized test:
Check all that apply during standardized tests:

Worry or dread Fear of failure Stress or Panic Increased heart rate Restlessness Excessive sweating Dry mouth Shortness of breath / Hyperventilation Headache or Migraines Stomach Ache or Nausea Lightheadedness Vomiting Difficulty Concentrating "Freezing" or "Going Blank" Disrupted attention/ easily distracted Difficulty reading relatively simple instructions Difficulty recalling or organizing relevant information Intrusive thoughts and sounds
If you are seeking accommodations assistance or would otherwise like us to have documentation of your disability on file (i.e. accommodations paperwork or documentation of your diagnosis), please feel free to attach it here.

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Terms and Conditions
This agreement constitutes the entire understanding between the parties with regard to the subject matter thereof and the parties waive the right to rely on any alleged expressed or implied provision not contained herein. Any alteration to this agreement must be in writing and signed by both parties.
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Student Registration Form

Billing Info

Student Education & Testing History

Test Anxiety Diagnostic

Terms and Conditions