FIND ME A TUTOR!
With Ava White Tutorials, Inc.
Date
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Month
-
Day
Year
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Student's Name
*
First Name
Last Name
Current School
Current Grade/Grade Completed
During summer months, the student is still considered to be in the grade they recently completed. They change grades officially at the start of each school year.
Birthdate
Age
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent Name
*
First Name
Last Name
Parent Email
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Texting's ok?
Yes
No
Who can we thank for referring you to us?
What type of tutoring are you looking for?
*
Struggling with a specific subject
SAT Test Prep
ACT Test Prep
Additional support to give me/my child confidence in the classroom
Other
Please check which areas of the SAT/ACT are needing help with tutoring.
English (Verbal)
Math/Science
General Test Prep (All Areas)
Are you or your student currently registered for an upcoming SAT/ACT test date?
Yes
No
What is the test date?
Please give any explanations as to why you/your child needs tutoring.
What are your expectations for tutoring?
Special Considerations?
Is your child currently taking any medications?
Yes
No
What medication is he/she taking?
Has your child had any sort of professional testing done?
*
Yes
No
If yes, what tests?
Does your child currently have an IEP (Individualized Education Plan)?
Yes
No
Could we have a copy of the IEP?
Yes
No
Has your child had a Psychological Evaluation in the past three years?
Yes
No
Can we have a copy of the evaluation?
Yes
No
Best Days for Testing/Tutoring?
Monday
Tuesday
Wednesday
Thursday
Friday
Weekend
Best Time for Testing/Tutoring
Mornings (8:00 - 12:00)
Afternoon (12:00 - 5:00)
Evenings (5:00 - 8:00)
Questions or Comments
Please upload any documents you think we might need to see!
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IEPs, Psychological Evals, Other Testing, etc.
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