Tutoring Session Reservation

1
Student Name* This field is required.
First Name
Middle Name
Last Name
2
Student DOB* This field is required.
3
Gender* This field is required.
Please Select
Male
Female
N/A
4
Preferred Location
Please Select
Please Select
Hernando Location
Ocala Location
Gainesville Location
Online attendance
5
Student E-mail* This field is required.
example@example.com
Confirm Email
6
Requested-Start-Date* This field is required.
Date
Year
Month
Day
7
What nursing school do you attend?* This field is required.
Name of School and nursing degree/diploma you will receive.
When are you scheduled to graduate?
8
In what Nursing Concept do you need Tutoring?* This field is required.Select from list below
Please Select
Please Select
1) Cardiovascular system
2) Respiratory system
3) Renal system
4) Musculoskeletal system
5) Gastrointestinal system
6) Immunological & Hematological systems
7) Neurological system
8) Endocrine system
9) Integumentary system
10) Gero-sensory
11) Reproductive systems
12) Mental Health/Psych
13) Pediatric nursing
14) Pharmacology and Dosage Calculations
15) Delegation and Prioritization
16) Mastery of Assessment skills
Nursing topic focus areas
9
NURSING EDUCATION TUTORING SESSION

Statement of Acknowledgment:

I, (sign your name below) hereby do solemnly swear under possible penalty of perjury that the information contained here is true. I have been told that tutoring membership sessions do not guarantee my success on nursing school degree completion or NCLEX-RN. I understand that I have three hours every month to attend a paid scheduled group session. I know that private sessions are paid by an hourly rate. I have read tutoring session information and had all my questions answered prior to signing this form. I know that all tutoring attendance fees are completely non-refundable and non-transferrable. I have retained a copy of this signed acknowledgment for my records.
10
Nursing Tutoring Options
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Tutoring Monthly Membership---> Group InstructionOnsite or Online option 3hr tutoring sessions. Rate is per each attendee.
$75.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Tutoring Session---> Private Instruction OnsiteCost is per hour rate.
$75.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Subtotal: $0.00
Tutoring Session---> Private Instruction OnlineCost is per hour rate.
$75.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Subtotal: $0.00
Total cost $0.00
Credit Card
First Name
Last Name
11
Copy of Driver's License if paid with Credit Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Signature* This field is required.Sign below
Powered by Jotform SignClear
Should be Empty: