CLG Interest Form

1

Parent NameName of the parent/guardian filling out the form

First Name

Last Name

2

Phone NumberPhone number you wish to be contacted on

Area Code

Phone Number

3

EmailBest email to contact you

example@example.com

4

Child’s Informationwhat is their first name, grade level, and school they attend. Also, describe their strengths and interests, please.

5

Child’s StrugglesPlease describe the struggles your child faces. Are they recent or has this been ongoing?

7

Good times to call

9a -11a

11a-1p Lunchtimes

1-3p

6-8p, not Friday

8

Interested in…

Virtual Tutoring (anywhere in the USA)

In-person Tutoring (Acadiana Area)

Parent Support Consultation

Academic Support Consultation (review of academic records)