Huber Tutoring
Student Registration Form 2023-24
Designed for 1st through 12th grade students.
Parents are encouraged to come and participate!!
Today's date
*
-
Year
-
Month
Day
Date
Student's Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Student's Mailing Address
*
Street Address
Apartment
City
State / Province
Postal / Zip Code
Phone Number:
-
Area Code
Phone Number
Email:
example@example.com
Name of school:
*
Grade:
*
Are you a member of Huber Memorial Church
*
Yes
No
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone#
*
-
Area Code
Phone Number
Parent/Guardian Email
*
example@example.com
Please indicate the name and phone number of the personwho will be bringing the student to tutoring (if not Parent or guardian.)
Tell us, what area(s) of math or reading does the student need help?
*
Does student have any special needs, including medical needs, that we need to be aware of?
*
Yes
No
If yes, please clarify:
Is the student presently passing math?
*
Yes
No
Is the student proficient in reading?
*
Yes
No
Is the student assigned math or reading homework, daily?
*
Yes
No
Is the student using a computer basic math program?
*
Yes
No
In case of emergency
Contact In Case of Emergency
*
First Name
Last Name
Relation
*
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Apartment
City
State / Province
Postal / Zip Code
Submit
Should be Empty: