Reading Tutor Rx Registration
Student's Information
Student's Name
First Name
Last Name
Age
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Student's Email
example@example.com
Student's Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name
School/Grade Level
What colleges are you applying to?
Student's Photo (Optional)
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Parent Email
example@example.com
Parent Phone
IEP/504 Information
Preferred Days/Times of Sessions
Parent/Guardian Information
The parents/guardian listed below will be the authorized person to pick-up the child after a session.
The parents/guardian listed below will also be the primary emergency contact person.
Name
First Name
Last Name
Relation
Phone Number
-
Area Code
Phone Number
Picture upload
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Name
First Name
Last Name
Relation
Phone Number
-
Area Code
Phone Number
Picture upload
Browse Files
Cancel
of
Medical Information
Does the child have any allergies? If yes, please list them below:
Does the child have any previous injuries? If yes, please explain them below:
Does the child have any current medical conditions? If yes, please list them below:
Does the child takes any medication? If yes, please list them below and explain its purpose:
Refund Policy
Refund Policy for Tutoring Session PackagesWe strive to provide high-quality tutoring services tailored to each student’s academic success. However, we understand that circumstances may change. Please review our refund policy below for tutoring session packages:1. Cancellation & Refund EligibilityFull Refund: A full refund will be issued if requested within 7 days of purchase and no sessions have been used.Partial Refund: If some sessions have been used, a pro-rated refund will be issued for the unused sessions, minus a 10% administrative fee.No Refunds: Refunds will not be issued after 30 days from the purchase date, regardless of usage.2. Missed or Cancelled SessionsSessions must be cancelled at least 24 hours in advance to reschedule or receive a credit.Sessions cancelled with less than 24 hours’ notice or no-shows will be counted as used and are non-refundable.3. Package ExpirationAll tutoring session packages expire 6 months from the date of purchase. Unused sessions after expiration are non-refundable and non-transferable.4. Exceptional CircumstancesWe understand life happens. Exceptions to the policy may be made on a case-by-case basis due to emergencies, with appropriate documentation.5. Refund ProcessTo request a refund, please email [your support email] with your name, purchase details, and reason for the request. Approved refunds will be processed within 7–10 business days.
Payment Details
Parent/Guardian Signature
My Products
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Starter Boost
$
400.00
2 Sessions (4 hours total)
Confidence Builder
$
1,000.00
5 Sessions (10 hours total)
Top Score Intensive
$
2,000.00
10 Sessions (20 hours total)
Elite Ongoing Prep
$
3,200.00
2 Sessions per weeks (32 hours total)
Registration Fee
$
25.00
ESA GRANT
$
Free
Invoice will be generated to submit to Class Wallet
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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