New Client Intake Form
Please provide the following information prior to your child's first session. If you are seeking tutoring for more than one student, you may provide information about both students on the same form.
Full 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
How did you hear about us?
*
Please Select
Referral
Website
Google search
Instagram
Facebook
Other
Please specify who referred you
*
Please specify which website
*
If you used google, what search terms did you use?
*
If "other", please specify
*
Student Name(s), Grade Level(s), and Requested Subjects
*
Preferred Days/Times for Tutoring Sessions
*
Background Information on Student(s)
*
Please
read our policies and procedures at
https://www.atxclassroom.com/policies-and-procedures
.
I agree to abide by the policies and procedures outlined in the link above, and I vow to not hold Valeria Portugal or ATX Classroom LLC responsible if I breach these procedures. Policies and procedures are subject to change.
*
I have read and agree to the Policies and Procedures.
I agree to use electronic records and signatures.
Signature
*
Submit
Should be Empty: