Registration Form
2025-2026 School Year
Student Name
First Name
Middle Name
Last Name
Parent Email
example@example.com
Parent Name
First Name
Last Name
Parent Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Frequency of sessions
Please Select
1x (60 min) session a week
2 x (60 min) sessions a week
Homeschool: 3 hours a week or more 2 x (90 min)
Format of sessions
Please Select
Online
In Person
School Name and District (N/A if homeschooled)
Example: Bolton Academy, Atlanta Public Schools
Select the best way for us to track school progress (grades, modules, syllabus, classwork):
School Portal
Weekly Newsletters
I'm not sure
Student grade
Please Select
Pre-K
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Adult
What days do you prefer for tutoring?
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
What hours of the day do you prefer?
Homeschool hours: 10am-3pm
3pm-4pm
4pm-5pm
5pm-6pm
7pm-8pm
When do you want to start tutoring?
-
Month
-
Day
Year
Date
Does the Student have an IEP? (for students with special needs)
Yes
No
Not yet but needs to be tested
If your child has an IEP or 504 Plan, please list what for. Skip this question if your child does not have a learning disability or health impairment.
Second Parent Name (Optional)
Second Parent Email (Optional)
example@example.com
Second Parent Phone Number (Optional)
Format: (000) 000-0000.
Please indicate any additional services you would like more information about:
IEP Advocacy
College Advising and Job Readiness
Chrysalis Club Pre-Teen Girl's Group
Executive Functioning Coaching
Please list any dates you will not be available for tutoring (i.e., travel dates)
Optional: Is the student on medication for ADHD?
N/A
Yes, I give them a prescription according to my doctor's recommendation
No, I am looking for natural alternatives for my child's ADHD
No, my child can manage their ADHD with coping skills
Kind of: I give meds to my child when needed but not every day
Please upload your child's most recent report card:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
When did you first begin to be concerned about your child's school performance?
What are your current goals for your child? How do you want to see them improve?
Please sign to acknowledge our 24-hour cancellation policy. You must contact us as soon as possible to cancel a session. No show appointments will still be charged.
We look forward to helping your child succeed!!
Welcome to the Holistic Edu Family.
Continue
Continue
We look forward to serving you and your family
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