Summer Tutoring Targeted Academic Support Registration

Summer Tutoring - Targeted Academic Support Registration Form
Welcome to the EduKation Solutions Summer Tutoring: Targeted Academic Support Program!

Thank you for your interest in enrolling your scholar in our summer academic program. Designed for scholars in Grades K–8 and Rising 9th Grade, this program provides targeted academic support in Reading, Writing, and Mathematics through small-group instruction, individualized learning plans, data-informed strategies, realistic goal setting, daily progress monitoring, and engaging real-world learning projects.

Our goal is to strengthen foundational skills, improve academic performance, build confidence, and help scholars maintain and accelerate their learning throughout the summer months.

Program Details:

• Dates: June 15, 2026 – July 17, 2026

• Time: 8:30 AM – 12:30 PM, Monday–Friday

• Location: The Annex Building, 7757 S. Greenwood Ave., Chicago, IL 60619

• No Classes: June 19, 2026 (Juneteenth) and July 3, 2026 (Independence Day)

• Culminating Event: Scholar Showcase & Family Celebration on Friday, July 17, 2026

Important Registration Information:

• Please complete one registration form for each scholar you wish to enroll.

• A separate form and registration fee are required for each scholar.

• Registration is not considered complete until all required information has been submitted and payment has been received.

• Space is limited and enrollment will be accepted on a first-come, first-serve basis.

We look forward to partnering with your family and supporting your scholar’s academic growth this summer!
SECTION 1 - STUDENT INFORMATION
Student’s First Name
Student’s Last Name
Date of Birth

MonthDayYear
Date
Gender
Home Address
City
State
Zip Code
Current Grade Level
Grade Level for Fall 2026
School Currently Attending
SECTION 2 - PARENT/GUARDIAN INFORMATION
Parent/Guardian #1

First NameLast Name
Relationship to Student
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address - Street
City
State
Zip Code
Would you like to add a second Parent/Guardian to this registration?
Parent/Guardian #2

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
SECTION 3 - STUDENT MEDICAL INFORMATION
Does your child have any medical conditions, or allergies?
If yes, please explain the medical conditions, or allergies.
Will your child need to take prescription medication during program hours?
Prescription Medication Details
Please provide the following information for each prescribed medication: medication name, prescribed dosage, frequency/time of administration, and any special instructions for program staff.
SECTION 4- EMERGENCY CONTACTS
Emergency Contact #1 First & Last Name
Relationship to Student (Emergency Contact #1)
Phone Number (Emergency Contact #1)
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name
Relationship to Student (Emergency Contact #2)
Phone Number (Emergency Contact #2)
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 5 - STUDENT LEARNING PROFILE
Academic Areas Needing Support
Please describe any additional areas where your scholar may benefit from support.
Does your child have an IEP, 504 Plan, or receive special education services?
Please bring the following documents on your child's first day of the program
Please bring the following documents on your child's first day of the program (Monday, June 15, 2026): • Most recent Report Card • Most recent Assessment Reports (Star 360, i-Ready, etc.) • IEP (if applicable) • 504 Plan (if applicable) • Any additional academic reports or teacher notes Questions? Contact us at success@edukationsolutions.com
SECTION 6 - HOW DID YOU HEAR ABOUT US?
How did you hear about EduKation Solutions?
SECTION 7 - PERMISSIONS, CONSENT, and AGREEMENT SIGNATURES
- I am the parent or legal guardian of the student listed on this registration form.
- I understand that the EduKation Solutions Summer Targeted Academic Support Academy is an educational support program designed to provide academic enrichment and intervention services.
- I understand that a non-refundable Program Deposit of $75 is required to reserve my child's seat in the program.
- I understand that the weekly program fee is $100 per week, due each Monday, and that all payments made to EduKation Solutions are non-refundable. Invoices will be sent 2-4 days prior to each weekly due date.
- I understand that enrollment is not considered complete until payment has been received and confirmed by EduKation Solutions. Payments submitted via Zelle will be confirmed within 24 hours of receipt at success@edukationsolutions.com.
- I authorize EduKation Solutions staff, contractors, employees, and Learning Coaches to provide educational services and academic support to my child during program hours.
- I agree to provide accurate and complete information regarding my child's educational history, academic needs, and emergency contact information.
- I understand that EduKation Solutions reserves the right to remove a student whose behavior presents a safety concern or substantially disrupts the learning environment.
- I release and hold harmless EduKation Solutions, its officers, employees, contractors, volunteers, and partnering organizations from claims arising from ordinary participation in program activities, except where prohibited by law.
- I acknowledge that EduKation Solutions does not guarantee specific academic outcomes, test score increases, or grade improvements. Academic growth is dependent upon student participation, attendance, and effort.
Photograph and Video Release Authorization
Agreement to Program Policies and Expectations
Parent/Guardian Signature (Typed Name) – Consent and Release
Date

MonthDayYear
Date
SECTION 8 - PAYMENT POLICY
- A non-refundable Program Deposit of $75 is required to reserve your child's seat. Enrollment is not confirmed until the deposit is received.
- The Weekly Program Fee is $100, due each Monday. Invoices will be sent 2-4 days prior to each due date.
- Weekly Program Fee Payment Schedule:
- Week 1 — Mon, June 15 | Week 2 — Mon, June 22 | Week 3 — Mon, June 29 | Week 4 — Mon, July 6 | Week 5 — Mon, July 13
- If the Program Deposit + Week 1 Program Fee ($175) is paid at registration, your next payment will be due Monday, June 22, 2026.
- If the Full Program Fee ($575) is paid at registration, no further payments are required.
- Zelle payments: Send to success@edukationsolutions.com — include your child's full name in the memo. Confirmation will be sent within 24 hours.
- All payments are non-refundable.
Payment Method
Zelle instructions
To complete your registration via Zelle:

Send payment to: success@edukationsolutions.com
Include your child's full name in the memo
Payment amounts:

Program Deposit Only — $75
Program Deposit + Week 1 — $175
Full Program Fee — $575


You will receive a payment confirmation within 24 hours of receipt which will officially confirm your child's enrollment
Weekly program fees of $100 are due each Monday. Invoices will be sent 2–4 days prior to each due date

All payments are non-refundable.
If Other, please specify
Please select one Program Fee payment option below.

Your total will reflect your selection automatically. If you wish to change your selection, please choose a different option.
Program Fee Selection
prevnext( X )
Program Deposit (minimum payment requirement)
Secures your child's enrollment. First program fee due Mon, June 15, 2026

$75.00 Quantity
Item subtotal:$0.00



Program Deposit + Week 1 Program Fee
$75 deposit + $100 Week 1. Next payment due Mon, June 22, 2026.

$175.00 Quantity
Item subtotal:$0.00



Full Program Fee — 5 Weeks
$75 deposit + $500 (5 weeks at $100). No further payments required.

$575.00 Quantity
Item subtotal:$0.00



Total

$0.00
Should be Empty:

Summer Tutoring - Targeted Academic Support Registration Form

SECTION 1 - STUDENT INFORMATION

SECTION 2 - PARENT/GUARDIAN INFORMATION

SECTION 3 - STUDENT MEDICAL INFORMATION

SECTION 4- EMERGENCY CONTACTS

SECTION 5 - STUDENT LEARNING PROFILE

SECTION 6 - HOW DID YOU HEAR ABOUT US?

SECTION 7 - PERMISSIONS, CONSENT, and AGREEMENT SIGNATURES

SECTION 8 - PAYMENT POLICY

Program Fee Selection*

Program Fee Selection