Academic Tutoring Interest Form
Applied Behavioral Approaches
Parent/Guardian Information
Name
*
First Name
Last Name
Relationship
*
Mother, Father, Grandparent, etc.
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Information
Name
*
First Name
Last Name
Gender
*
Female
Male
Birthdate
*
/
Month
/
Day
Year
Date
Which grade is your son or daughter in?
*
Pre-K
First
Kindergarten
Second
Does your child have an IEP or 504 Pllan?
*
Yes
No
Does your child have any special needs that require 1:1 support?
*
Yes
No
Does your child have a clinical diagnosis(es) of any of the following? (Check all that apply)
*
None
AD/HD
Autism
Down Syndrome
Intellectual Disability
Dyslexia
Global Developmental Delay/Significant Developmental Delay
Language Disorder
Other
What are your child's toilet training needs?
*
Not toilet-trained; currently wearing diapers.
Successfully goes to the bathroom with assistance if verbally reminded; if not accidents occur.
Can independently complete all tasks surrounding going to the bathroom, but lacks the skill to vocalize the need to use the restroom.
Is completely toilet trained, can identify when they need to “go”, will notify an adult/caregiver of this and will use the toilet independently without assistance.
School Attending or Zoned For
*
If your child has never attended any type of schooling, put N/A. If home-schooled please indicated "Homeschool".
Class Type & Grade
*
General education Pre-K, Special education Pre-K, Gen Ed 1st grade, etc.If your child has never attended any type of schooling, put N/A.
Tutoring Preferences
Tutoring Focus Area(s) Desired
*
Math
Reading
Science
Social Studies
Hours of attendance desired (clinic hours are 9:00 am to 2:00 pm)
*
Full day
Half-day morning (9:00 a.m. - 11:00 a.m.)
Half-day afternoon (12:00 p.m. - 2:00 p.m.)
Other
Days of the week desired
*
Monday
Tuesday
Wednesday
Thursday
Friday
Please provide any additional information here: Learning strengths and challenges, current medications, allergies, therapies, or chronic health concerns.
Please verify that you are human
*
Submit
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