Student Registration Form – Specialized Tutoring Program 2026–2027
Please complete this form to begin the enrollment process for the 2026–2027 academic year starting September 7, 2026. Have relevant details ready for a smooth registration.
Parent / Guardian Information
Parent / Guardian Full Name
*
First Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Legal Guardian
Other
Email Address
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Second Parent / Guardian (Optional)
Second Parent / Guardian Full Name
First Name
Last Name
Relationship to Student
Email Address
example@example.com
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student Information
Student Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Grade as of September 2026
*
Please Select
Pre-K
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Returning Learn and Lead Student?
*
Yes
No
Health & Additional Information
Please describe your child’s strengths, challenges, and what you hope to achieve through tutoring
*
Scheduling Preferences
Preferred Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Times
*
3:30 - 4:30 (Fridays)
4:30 - 5:30 (Mondays to Fridays)
5:30 - 6:30 (Mondays to Thursdays)
9:30 - 10:30 (Saturdays)
10:30 - 11:30 (Saturdays)
11:30 - 12:30 (Saturdays)
School Day Daytime Options (Mondays - Fridays)
Desired Weekly Sessions
*
Please Select
1 session per week
2 sessions per week
3 sessions per week
How did you hear about Learn and Lead?
Please Select
Word of mouth
Social media
Returning family
School referral
Other
Consent & Acknowledgement
By submitting this form, I confirm that the information provided is accurate and I understand that an initial consultation ($125) is required as the first step. Should you choose to proceed with classes following the consultation, I acknowledge Learn and Lead's cancellation policy: 24-hour advance notice is required for cancellations, and a 50% credit will be applied to the following month's invoice for sessions cancelled with proper notice.
I have read and agree to the above.
*
I have read and agree to the above.
Submit Registration
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