Apple Tree Tutoring Enrollment Form

Thank You for Choosing Apple Tree's Learning Support Program!

This is our official enrollment form, which will take approximately 30 minutes to complete per child. Please make sure you have enough time to finish the entire form in one sitting! Additionally, please ensure you have all the required information and documents ready (listed on our website).
Did someone refer you to Apple Tree? If so, please let us know who so we can thank them!

Student Information
First Name:*
Last Name: *
Middle Name:
Date of Birth:*

MonthDayYear

Student Information, continued
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Information, continued
Grade Level:*
Does your child need tutoring in Math, Reading, or Both?:*
Desired Start Date (Note: all start dates are on Mondays)*

MonthDayYear
Date
Last Week

MonthDayYear
Date

Student Ethnicity
Hispanic/Latino of any raceNon-Hispanic/Latino
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or more races

Parent/Guardian Information
First Name:*
Last Name:*
Middle Name:
Relationship to Student:*

Parent Information, continued
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com

Agreement
I hereby certify all information provided in this form to Apple Tree Educational Services to be correct and true. I authorize Apple Tree Educational Services to utilize and store this information for the purpose of maintaining my child's records.

I agree and undestand that any advice I receive from the staff at Apple Tree Educational Services is given in good faith. I understand that I am responsible for exercising my personal discretion in following any advice given by Apple Tree Educational Services. I will not hold Apple Tree Educational Services liable for my educational decisions. I agree to follow the laws and regulations regarding the education of my child, as set forth by the state of Florida and, if applicable, my local educational laws and regulations.

Apple Tree Educational Services does not discriminate on the basis of race, color, religion, creed, national origin, sex, disability, or age. Your family's privacy is incredibly important to us: your data is stored securely, and we will never share or sell your information to non-affiliated third parties, except as required by law.

By writing my name and today's date I am agreeing to the terms above and would like my child to be enrolled in Apple Tree Educational Services' Learning Support Program.
Name:*
Today's Date:*

MonthDayYear

Payment Method

Please advise your desired payment method: (a) Direct Pay through Step Up for Student's EMA; (b) Private Pay; (c) Reimbursement through a scholarship.
Payment Method*

Payment
Your total is shown below.

If you have selected Direct Pay, your balance will show as $0, and you will not be forwarded to PayPal. Please click Submit to send us your form.

If you selected Private Pay or Reimbursement, your balance will show as $950, which is due now. Upon submitting this form you will be forwarded to PayPal to complete your payment.
Cost
Order Total

prevnext( X )
USD
Should be Empty: