Academic Support Client Information Form

Client Registration Form
General Information
Client Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Ethnicity
Gender
Entry Year
Grade
Semester

Residence Information
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/ Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information
Primary Emergency | Contact Name

First NameLast Name
Primary Emergency | Phone Number
Please enter a valid phone number.
Primary Emergency | What is your relationship with this person?
Secondary Emergency | Contact Name

First NameLast Name
Secondary Emergency | Phone Number
Please enter a valid phone number.
Secondary Emergency | What is your relationship with this person?

Medical Information
Physician Name

First NameLast Name
Physician Primary Phone Number
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Preferred Emergency Hospital Name
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.
School Information
School Name
City
State
Does your child receive any special services (i.e. IEP, 504, BIP)? If yes, please detail.
Notes
Wednesday Session Availability - beginning week of August 30, 2021 (please choose one)*

5:00pm In-person5:30pm In-person6:00pm In-person
Submission of this form indicates agreement to academic support services for one semester (18 weeks). The responsible agrees to monthly payment draft from account by which registration costs are paid (unless otherwise arranged with GLS in writing). If your Statement of Work is for summer only sessions, submission of this form indicates your agreement to academic support services for the duration of academic support for the period of June and July at the current summer-only rate.*

I agree

My Products

Private Session RegistrationThis is a nonrefundable retainer fee for services. For transparency, the purpose of this fee is because many people register, GLS blocks off time, and the client does not fulfill their contractual obligation.

$30.00

Homeschool Tutoring This fee is a non-refundable deposit that will be applied to the first session.

$65.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature

Clear
Should be Empty:

Client Registration Form

General Information

Residence Information

Emergency Contact Information

Medical Information

School Information