Tutoring Registration

Tutoring Registration

In-Person, Virtual, and/or Hybrid Options
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Expected Start Date*

MonthDayYear
Programs run throughout the academic year
School Attending
Grade
Virtual or In-Person*
Please schedule 24hours before service.
Cognitive Learning Diagnosis

IEPDyslexiaADDADHDOther
Disclaimer for ACE Recipients: payments must be paid in full, reimbursement comes via the State and paid out directly to parent/guardian within 4-6 weeks.

I understand I will pay for sessions up front and comply with payment via reimbursement from the ACE program.
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Care # (In-person only)
Doctors Name (In-person only)

First NameLast Name
Doctors Phone Number (In-person only)
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*
Cell
Work
E-mail*
example@example.com
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
Parent/Guardian Information 2
Full Name

First NameLast Name
Home
Cell
Work
E-mail
example@example.com
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
Is your child immunized?*

YesNo
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?

YesNo
Please list the people authorized to pick up your child.
Does your child have any siblings?*
If yes, what is their age(s)?
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*
Cell
Work
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
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Registration FeeRegistration is non-refundable and is an annual fee.

$30.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

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

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Tutoring Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian