Summer 2026 Standard Enrollment Form

Parent | Guardian Information
Student primarily resides with
If OTHER, please describe
Primary Contact's Name

First NameLast Name
Primary Contact Relationship to Student
Primary Contact's Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact's Email
Ex. yourname@gmail.com
My preferred method of contact is:
Primary Contact's Address

Street Address

Street Address Line 2

CityState

Zip Code
Communication Regarding Your Child's Services
Marketing & Educational Communications
Illuminos Academic Coaching & Tutoring is committed to protecting your privacy. We do not sell, rent, or share your personal information with third parties for marketing purposes. Information collected during enrollment is used solely to provide and improve our services and to communicate with you regarding your child's participation in our programs.

Summer 2026

Pricing
I agree to pay Standard Pricing (billed every other week) in accordance with the terms below:
I would like to enroll in
I agree to pay the

Parent Consent to Communicate with Your Child's Circle of Support

We are happy to communicate and work with other support professionals in order to provide consistent & aligned support. Please complete a consent for each person you permit us to communicate with.
Student's Name

First NameLast Name
Therapists, Psychiatrists, Medical & Educational Providers

Please complete this section to allow us to work with other professionals supporting your child.
** For mental health & healthcare providers, you may also be required to complete a consent form directly with the providers to allow them to communicate with us.
Provider Name

First NameLast Name
Provider's Title
Provider's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider's Email
i.e. yourname@gmail.com
Provider Name

First NameLast Name
Provider's Title
Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider Email
i.e. yourname@gmail.com
Please share info on additional providers that you'd like to add so we can provide you with additional consent forms
Parent or Guardian's Name

First NameLast Name
Parent or Guardian's Email
example@example.com
Parent or Guardian's Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
AUTHORIZATION TO COMMUNICATE

By signing below, I authorize Illuminos Academic Coaching, its employees, coaches, contractors, and representatives who are subject to Illuminos' confidentiality obligations to communicate and share information regarding my child with the individuals and organizations identified in this Authorization for the purpose of coordinating and supporting my child's success.

I understand that I may revoke this Authorization at any time by providing written notice to Illuminos Academic Coaching, including by email. Any revocation will apply only to future communications and will not affect information shared prior to receipt of the revocation notice.
Please sign to authorize us to communicate with those you have list as stated above.

Illuminos Service Details and Policies

Terms & Conditions
- NEW STUDENT INTAKE PROCESS
  
  Enrollment Forms and Overview
  
  Once you complete and submit your student's enrollment forms, our team will review the information and prepare for the Evaluation Meeting. Within one business day of receiving your completed enrollment forms, you will receive instructions for your child to complete the required Executive Function Assessment. Please schedule your Evaluation Meeting at least 48 hours after submitting your enrollment forms. This allows time for your child to complete the assessment and for us to receive the results. This meeting must include at least one parent or guardian and the student who will be participating in coaching. You will have the opportunity to schedule this meeting during the enrollment process.
  
  Our Executive Function Assessment Powered by MindPrint®
  
  As discussed during your consultation, we use the MindPrint Learning Assessment, which was developed through a grant from the National Institutes of Health (NIH) to the University of Pennsylvania Medical Center and the Children's Hospital of Philadelphia. A similar version of this assessment is also used by NASA to evaluate adults. The assessment provides a detailed picture of how your child learns. The resulting Learner Profile identifies strengths and challenges, explains how those areas may affect learning, and provides evidence-based strategies to support success. The information helps parents better understand how their child learns and allows us to customize our coaching approach based on each student's needs. All students are required to complete this assessment. The assessment fee is outlined in your onboarding paperwork and detailed in the New Student Enrollment Information Email ("Enrollment Email"). This fee includes the assessment, Learner Profile, and a consultation to review the results and discuss how they will be incorporated into your child's coaching plan.
  
  Evaluation Meeting
  
  As part of the onboarding process, a member of our team will meet with you and your child by video conference for an extended interview lasting approximately 60 to 90 minutes. During this meeting, we will discuss your child's goals, strengths, challenges, school experience, study habits, interests, activities, and support needs. We will also discuss your goals and priorities for coaching. Combined with the assessment results and enrollment information, this meeting helps us develop a coaching plan and determine which coach on our team is the best fit for your child.
  
  Coach Matching
  
  Following the Evaluation Meeting, we begin the process of selecting a coach for your child. While most students are matched within 5 to 7 business days, the process may take longer during peak enrollment periods, particularly between August and October and January and March. Once a coach has been selected, you will receive a Coach Match Email containing information about your coach's background, experience, qualifications, and hourly rate, along with details regarding your child's first session.
  
  Your First Session
  
  Your Coach Match Email will include the format, date, time, and location of your child's first session, along with any additional information you may need before getting started.
- Additional Information and Payment Terms.
- Please SIGN Below

Next Step - Credit Card Authorization

Once you submit, you'll be directed to authorize your credit card. Enrollment is NOT complete or accepted without the credit card authorization. *Please be patience as the page loads. Do not close the page.
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Your Child's Information

Parent | Guardian Information

Summer 2026

Parent Consent to Communicate with Your Child's Circle of Support

Therapists, Psychiatrists, Medical & Educational Providers

Illuminos Service Details and Policies

Next Step - Credit Card Authorization