Academics With Alex student registration form
Please fill in the form below.
Parent Information
Parent Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Emergency contact name
*
First Name
Last Name
Emergency Contact No.
*
In order to better assist families, AWA offers payment plans, sliding scale fees, etc. Are you in need of assistance?
*
Please Select
Yes
no
I'll let you know
Student Information
Student(s) name
*
Student(s) name
Gender
*
Please Select
Male
Female
Gender
Please Select
Male
Female
current grade :
*
Please Select
KG
1st
2nd
3rd
4th
5th
6th
7th
8th
current grade :
Please Select
KG
1st
2nd
3rd
4th
5th
6th
7th
8th
School type
*
Please Select
home
public
private
charter
School type
Please Select
home
public
private
charter
Subject area (s)
*
Math
Reading/Writing
Subject area (s)
Math
Reading/Writing
Does the student struggle to stay on task?
*
Please Select
yes
no
a little
not sure
Does the student struggle to stay on task?
Please Select
yes
no
a little
not sure
Does the student have trouble staying in his or her seat at school?
*
Please Select
yes
no
not sure
Does the student have trouble staying in his or her seat at school?
Please Select
yes
no
not sure
Please select unique learning abilities
*
Autism
ADHD
ADHD combined
not sure
none
Other
Please select unique learning abilities
Autism
ADHD
ADHD combined
not sure
none
Other
Does this student struggle with letter, number, or basic sound recognition?
*
Please Select
yes
no
somewhat
not sure
Does this student struggle with letter, number, or basic sound recognition?
Please Select
yes
no
somewhat
not sure
This student's reading level is..
*
Please Select
low
moderate
high
not sure
This student's reading level is..
Please Select
low
moderate
high
not sure
This student's math level is...
*
Please Select
low
moderate
high
not sure
This student's math level is...
Please Select
low
moderate
high
not sure
Include Standardized test prep
*
Please Select
yes
no
This Student is taking the..
*
Please Select
FAST
STAR
N/A
Please give any additional information about the student's academic needs
*
Please tell me your child's favorite color, animal, hobbies, etc.
*
Can your child participate in rewards day? This is done once a month
*
Please Select
yes
no
Please list any allergies
*
Session Details
Are you interested in Summer tutoring?
*
Please Select
yes
no
maybe
Preffered Time
*
Please Select
early morning 7-9
mid- morning 9-11
early afternoon 11-2
late afternoon 2-4
late evening 5-7
I prefer service in...
*
Please Select
Home
In office (Winter Haven)
My local library
Are there any animals in the home?
Please Select
yes,cat(s)
yes, dog(s)
no/NA
Number of sessions requested
*
Please Select
1 weekly
2 weekly
twice monthly
three monthly
Session length
*
Please Select
60 minutes
75 minutes
90 minutes (additional cost)
120 minutes (additional cost)
Length of service desired?
*
Please Select
2 months
4 months
6 months
Full School Year
Specialized Services
Academics With Alex has partnered with a licensed speech therapist, a licensed psychologist/educational evaluator, and a pediatric occupational therapist who provides coaching services for children. Families no longer need to search for outside providers —support is available right here through AWA.
Are you interested in any of these services?
*
Please Select
Speech Therapy
Educational Evaluation
Pediatric OT Coaching
Not at this time
Payment Information
I understand that Academics with Alex does not accept cash, cash app, Venmo etc. A card must be placed on file for all payments*
*
Please Select
yes
After registration is complete there are additional documents that must be reviewed and signed in person*
*
Please Select
ok
Preferred payment cycle:
Please Select
weekly
biweekly
monthly (Onlyfor Step Up)
My Products
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