J D Green Educational Services Student Registration Form
25-26 Academic School Year
Student Name
*
First Name
Last Name
Student Email
*
example@example.com
Student Phone Number
School Name for the 2025-2026 Academic Year
*
Student Grade Level for the 2025-2026 School Year
*
Please Select
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
College
Other
Preferred Days for Tutoring
Sunday
Monday
Tuesday
Wednesday
Thursday
Preferred time for tutoring
Please Select
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11;30 am
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
With whom does student reside?
*
Parent/Guardian #1 Name
*
First Name
Last Name
Parent/Guardian #1 Email
*
example@example.com
Parent/Guardian #1 Phone Number
*
Parent/Guardian #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/ Guardian #2 Name
First Name
Last Name
Parent/ Guardian #2 Email
example@example.com
Parent/ Guardian #2 Phone Number
Person Responsible for Payment
*
Person Responsible for Payment Phone Number
*
Person Responsible for Payment Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Academic Concerns
Social Concerns
Medical Concerns
Other Information
Please upload IEPs, 504s, Report Cards, etc.
Browse Files
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REGISTRATION FEES ***NO REFUNDS***
*
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NON REFUNDABLE Materials Fee ***RETURNING STUDENTS ONLY***
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
NON REFUNDABLE Registration/Materials Fee **NEW STUDENTS**
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
Submit
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