New Customer Registration Form

Gold Star Tutoring Summer Program Registration Form
Welcome to the Gold Star Tutoring Summer Program registration form. Please read the information below and complete all required fields before submitting.
Thank you for your interest in Gold Star Tutoring's Summer Program! Please complete the form below to reserve your child's spot. Spaces are limited and filled on a first-come, first served basis.
Parent/Guardian Full Name
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Student Information
Student Name

First NameLast Name
Grade Level
Academic Needs

What areas does your child need support in?
Academic Needs

Other
Other
Academic Concerns
Briefly describe your child's academic needs or concerns
Program Selection
Preferred Start Session
Preferred Start Session
Payment and Registration

Choose One:
Registration Option
A $100 non-refundable deposit is required to reserve your child's spot. Remaining balance due by June 1.
Program Investment Acknowledgement
How did you hear about us?
Please Specify
Will you be willing to recommend us?
Program Investment Acknowledgement
Should be Empty:

Gold Star Tutoring Summer Program Registration Form