PARENTAL INFORMATION
Title
Please Select
Dr.
Mr.
Mrs.
Ms.
Rev.
Parent's First Name
Last Name
Parent's Address
City
State
Please Select
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
Please Select
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
Please Select
1
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5
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9
10
Comments
Reading
Please Select
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10
Comments
Literature
Please Select
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10
Comments
Writing/Composition
Please Select
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10
Comments
Social Studies/History
Please Select
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Comments
Science
Please Select
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Comments
Computers
Please Select
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10
Comments
Art
Please Select
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10
Comments
Music
Please Select
1
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9
10
Comments
Physical Ed/Sports
Please Select
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10
Comments
Organization
Please Select
1
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10
Comments
Test Taking
Please Select
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10
Comments
Note taking
Please Select
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Comments
Asking for help
Please Select
1
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Comments
Study Habits
How much time do you spend helping your student complete homework?
Please Select
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?
Please Select
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?
Please Select
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
Other
My student likes homework
Yes
No
Rate your student's self esteem (1 - Low 10 - High)
Please Select
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
Other
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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