DPI Tutoring Application

Dennene's Preschool Inc. Tutoring Services Application

Serving Kindergarten to 3rd Grade

Email: dennenespreschool@gmail.com

Website: www.dennenespreschool.com

Name of Student*

Date of Birth*

Current Grade Level:*

School Currently Attending

Does the student have an IEP or 504 Plan?*

If yes please provide details or documentation

Primary Academic Areas of Concern:*

Please select one option. If there are other areas of concern, please discuss with tutor during consultation.

Full Name of Parent or Guardian:*

Relationship to Student*

Phone Number*

Email Address*

example@example.com

Home Address

Preferred Days for Sessions:*

Preferred Time of Day:*

How many sessions per week are you requesting:*

Please list any allergies, medical conditions, or behavioral information we should be aware of.

Consent and Acknowledgement

By signing below, I certify that the information provided is accurate to the best of my knowledge.

I understand that submission of this application does not guarantee placement, and that tutoring services are subject to availability.

I agree to follow all DPI policies regarding scheduling, payment, and attendance as outlined in the tutoring agreement.

I give permission for DPI staff to communicate with me regarding my child's academic progress and, if needed, to collaborate with their classroom teacher or school (with written consent).

I understand that a submitted application does not constitute services. A contract must be signed and payment made to begin services.

Parent / Guardian Signature*