Date Today
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Month
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Day
Year
Date
Student Information
Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Current School
Please Select
Homeschool
Public School
Private School
Hifz/Alim Course
School Name
Gender
Grade Level
Please Select
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Information
Does your child have any allergies? If so, what allergies?
Does your child have any behavioral, physical, or medical conditions? If so, what conditions?
Any additional information you would like to share about your child?
Tutoring Information
Which Subject (Math, Reading, Quran, etc)
Are you currently registered in any Aim Academy programs?
Not currently registered
Homeschool Co-Op
Sunday Academics
Other
What After School Tutoring Type are you registering for? ($200 a month)
Individual Tutoring - 2 sessions a week
Group Tutoring - 3 sessions a week
Other
After School Tutoring runs Monday to Thursday from 4pm to 6pm. Please list any preferred timings, days, or tutors. We will try to accommodate you as best as possible.
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Parent/Guardian Information
Name of Father
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address (if different than student)
Name of Mother
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address (if different than student)
Email responsible for payment invoices
*
example@example.com
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Emergency Contact Information
Name
First Name
Last Name
Relationship to Child
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Home Address
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Approved Pickup Persons (Please list all the individuals that are allowed to pick up your child from a tutoring session)
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