The Math Table Registration form

Name of Person Completing this Form:*

Student First Name:*

Student Last Name:*

Student Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Student Phone (if Applicable)

Student Grade*

Student School*

e.g., Smith

BoyGirl

Student's Educational Needs:

Special Requests, questions or information you want to share:

Parent/Guardian Name (Required for minor students):

Parent/Guardian Email or Student Email for Adults*

Parent/Guardian Phone (Required for Minor Students):

2nd Parent/Guardian Name:

2nd Parent/Guardian Email:

2nd Parent/Guardian Phone:

I agree to the payment and cancellation policy of The Math Table, LLC

Self-PaySUFS Scholarship

I understand that The Math Table, LLC may only receive payment from the SUFS scholarship if the student attends the scheduled appointment. For appointments canceled within 48 hours or for appointments that the student does not show up, families are personally responsible for the session fee.

After your registration has been reviewed by The Math Table, you will receive information on how to proceed.