Virtual Tutoring Form

Name

First NameLast Name
Atlantis Academy Hybrid Learning Center

a division of Ruby A. Neeson Diabetes Awareness Foundation
Email
example@example.com
Name

First NameLast Name
Math Help = Better Grades = Better Health Outcomes
Our online tutoring is a part of an endeavor to bridge the health and education equity gap by putting forward an innovative solution to youth programming. Please note occasionally, sessions will include youth-friendly nutrition tips & resources to promote healthy habits.
Healthy Kids Club
Expected Start Date

MonthDayYear
Grade Attending
Math Level
Which online math tutoring session are you wanting to register for?*
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Full Name*

First NameLast Name
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail*
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Infomation
Are you familiar with Microsoft Teams videoconferencing?

YesNo
Comments
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
All registrations are received and reviewed on a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Should be Empty:

Atlantis Academy Hybrid Learning Center

Math Help = Better Grades = Better Health Outcomes

Healthy Kids Club

Student Information

Parent/Guardian Information

Other Infomation

Emergency Contact - Other than Parent/Guardian