PARENTAL INFORMATION
Title
Dr.
Mr.
Mrs.
Ms.
Rev.
Parent's First Name
Last Name
Parent's Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Phone Numbers Home
Cell
Office
E-Mail Address
STUDENT INFORMATION
Student's First Name
Last Name
Nickname
Age
Student's Gender
Male
Female
Current Grade
Current School
Reason for requesting an Eton Tutor Pro
My Student is struggling in school
I want my student to improve his/her current grades
My student has a difficult time completing homework
My student is failing one or more classes
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Please Rate Your Student By Subject/Activity
(1 - Weakness 10 - Strength)
Mathematics
1
2
3
4
5
6
7
8
9
10
Comments
Reading
1
2
3
4
5
6
7
8
9
10
Comments
Literature
1
2
3
4
5
6
7
8
9
10
Comments
Writing/Composition
1
2
3
4
5
6
7
8
9
10
Comments
Social Studies/History
1
2
3
4
5
6
7
8
9
10
Comments
Science
1
2
3
4
5
6
7
8
9
10
Comments
Computers
1
2
3
4
5
6
7
8
9
10
Comments
Art
1
2
3
4
5
6
7
8
9
10
Comments
Music
1
2
3
4
5
6
7
8
9
10
Comments
Physical Ed/Sports
1
2
3
4
5
6
7
8
9
10
Comments
Organization
1
2
3
4
5
6
7
8
9
10
Comments
Test Taking
1
2
3
4
5
6
7
8
9
10
Comments
Note taking
1
2
3
4
5
6
7
8
9
10
Comments
Asking for help
1
2
3
4
5
6
7
8
9
10
Comments
Study Habits
How much time do you spend helping your student complete homework?
Less than 15 minutes per day
15-30 minutes per day
30-60 minutes per day
More than 60 minutes per day
How often does your student take breaks while completing homework?
Every 5 minutes
Every 10 minutes
Every 20 minutes
Every 30 minutes
Every 60 minutes
Doesn't take breaks
Where does your student complete the majority of his or her homework?
Library
Bedroom
Den area or study area at home
Kitchen table
Friend's house
School
Other (please specify)
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While doing homework my student does: (Check all that are applicable)
Does homework right after school
Listens to music
Talks
Avoids all homework
Does homework in the early evening
Surfs the Internet
Avoids work in difficult subjects
Does homework late at night
Watches television
Gets sleepy
My student likes homework
Yes
No
Rate your student's self esteem (1 - Low 10 - High)
1
2
3
4
5
6
7
8
9
10
My student has the following learning challenges (Check all that apply)
None
Dysgraphia
ADHD
Non-verbal learning disability
Dyslexia
Processing challenges
Complete the following sentence
My goal is that an Eton Tutor Pro will help my student ...
Is there any other information you would like to share about your student?
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What days and times work best for tutoring?
Days and times requested are subject to availability.
How many days per week would you like to have tutoring?
1
2
3
Preferred Day(s) - Multiple selections allowed
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Start Time(s) - Multiple selections allowed - Sessions are 1 hour
3:30
4:00
4:30
5:00
5:30
Preferred Start Times - Summer Only - Multiple selections allowed
8:00
9:00
10:00
11:00
12:00
Any other scheduling information that would be helpful?
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