Academic Services Request Form

Academic Services Interest Form
Parent & Contact Information

Please make sure all information is accurate
Parent Name

First NameLast Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Student Information

Please make sure all information is accurate
Student's Name

First NameLast Name
Birth Date

MonthDayYear
My child is enrolled in

Other
Other explanation
If homeschooling, what curriculum (online or workbooks) do you use?
Name of School
Grade
Has your child ever been retained?
If any information, which grade were they retained? Add any pertinent information
2024-2025 Teacher
2025-2026 Teacher
Which services are you interested in?
Subjects for Tutoring
Frequency
Preferred Meeting Location
LOCATIONS FOR TUTORING

Fernandina Beach Library

25 N 4th St, Fernandina Beach, FL 32034

Monday 10 AM-8PM
Tuesday 10 AM-6 PM
Wednesday 10 AM-6 PM
Thursday 10 AM-8 PM
Friday 10 AM-6 PM
Saturday10 AM-6 PM
Sunday Closed

Yulee Library

76346 William Burgess Blvd., Yulee, FL 32097 (on the FSCJ Nassau Campus)

Monday: 10:00 AM – 12:30 PM, 1:30 PM – 6:00 PM
Tuesday: 12:00 PM – 4:00 PM, 5:00 PM – 8:00 PM
Wednesday: 10:00 AM – 12:30 PM, 1:30 PM – 6:00 PM
Thursday: 12:00 PM – 4:00 PM, 5:00 PM – 8:00 PM
Friday: 10:00 AM – 12:30 PM, 1:30 PM – 6:00 PM
Saturday & Sunday: Closed

Please note that these hours may be subject to change.

Best days and times to meet

Other
Preferred Start Date

MonthDayYear
Date
Does your child have an active IEP or 504 plan?
Has your child ever been evaluated by a psychologist through a formal psychoeducational assessment?
Has your child been diagnosed with any learning disabilities?

Other
Please list any services that your child currently receives
Tell us a little more about your child
Is your child struggling? If so, please explain.
What are your expectations for tutoring?
Do we have permission to reach out to your child’s teacher for guidance to support them?
How did you hear about us? Were you referred by anyone?
Should be Empty:

Academic Services Interest Form