Tutor /Coaching Youth Information Form

Tutoring and Coaching Supports – Mount Willow
Annie Baxter Tutoring & Wellness Coaching
Student Information & Consent Form

🌿 Welcome
My teaching style is warm, student-centered, and flexible. I focus on building a strong connection with each learner while creating a safe, supportive space for academic growth and emotional well-being. Sessions are tailored to meet your child's unique needs—whether through hands-on learning, structured routines, games, or confidence-building conversations.

Our tutoring integrates strength-based support, interactive learning, and skill-building designed to help students grow academically and socially from K–9, with specialization in Language Arts and social-emotional wellness.
Name
Phone
DOB

MonthDayYear
Date
Email
example@example.com
Childs First and last Name
Age
Grade
School
Diagnosed learning differences (if any): Academic strengths: Areas needing support: Social/emotional concerns:
Diagnosed learning differences if any
Academic strengths
Areas needing support
Social/emotional concerns
Second Child if Applicable
Name
Age
Grade
School
Diagnosed learning differences (if any): Academic strengths: Areas needing support: Social/emotional concerns:
Diagnosed learning differences if any
Academic strengths
Areas needing support
Socialemotional concerns
Annie Baxter MPCC- Provisional 403-872-8722

Tutor, Coach & Counsellor
K-12 Language Arts, Social Studies Elementary Math Homework Help & Test Prep Study Skills & Executive Functioning

Emotional regulation Stress/anxiety support Mindfulness & motivation Social-emotional learning

Note: Coaching is not therapy or mental health treatment.

K-5 45 minutes $50 /Grade 6+ 45- 60 minutes: $60

Youth Mentorship Program: Tutoring and Coaching combined -1hr $80
Main goals for tutoring
Best tutoring times
Preferred learning style
Tutoring and Coaching Supports
Which service do you want?

Tutoring OnlyYouth Mentorship broad scope( tutoring and coaching)
If you are registering for grade 6 + would you rather online or in person sessions?

OnlineIn personHybrid
Tutoring/Coaching & Holistic Wellness
By signing below, I acknowledge and agree to the following:
Policies & Expectations Cancellation Policy: A minimum of 24 hours’ notice is required for cancellations or rescheduling. Cancellations made with less than 24 hours’ notice will require full payment, unless there is an emergency. Emergency situations will be considered on a case-by-case basis at my discretion. Behavior & Communication To ensure a safe and respectful learning environment for everyone. Verbal abuse, disrespectful language, or aggressive behavior from students or parents/guardians will not be tolerated. If such behavior occurs, services may be paused or discontinued. I am committed to maintaining a space that is kind, supportive, and emotionally safe for all learners. Session Expectations: Students are encouraged to arrive prepared, with needed materials and a readiness to participate. Parents/guardians should communicate any changes in needs, concerns, or observations that may help support the student’s success.
Acknowledgment & Signature
I have read and agree to the terms above. Signature (Parent/Guardian or Student if 18+): Date:
Signature ParentGuardian or Student if 18

Clear
Date

MonthDayYear
Date
Any special concerns or requests: How did you hear about my services?
Any special concerns or requests
How did you hear about my services
Annie Baxter MPCC-Provisional 403-872-8722
Mountwillowplace@gmail.com
Should be Empty:

Second Child if Applicable

Tutoring and Coaching Supports

Tutoring/Coaching & Holistic Wellness

By signing below, I acknowledge and agree to the following:

Acknowledgment & Signature

I have read and agree to the terms above. Signature (Parent/Guardian or Student if 18+): Date:

Any special concerns or requests: How did you hear about my services?

Mountwillowplace@gmail.com