Parent 1 (Billing Responsible Party) Details:
This is the person who will be invoiced for the child’s sessions.
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
Street Address
City, State
Postal / Zip Code
Parent 2 (Non-Billing Responsible Party) Details:
This person is involved in the child’s learning process, but is not the person who will be invoiced.
Full Name
First Name
Last Name
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Student Details:
Student Name
*
First Name
Last Name
Student Grade, Age, and School County
*
Student Tutoring Subjects
*
Student Concerns
*
Student Tutoring Frequency
*
1x per week
2x per week
3x per week
4x per week
Appointment
*
Tutoring Times (please specify the times for the days you selected)
*
I agree to AK Learning Institute LLC payment and attendance policies and that I will pay weekly invoices by Tuesday of that tutoring week (failure to do so will result in cancellation of your session(s).)
*
I agree.
My student agrees to the AK Learning Institute LLC student and attendance policies.
*
I agree.
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other (Please specify...)
Would you liked to pay per package (monthly) or per sessions (weekly) -- you will be invoiced accordingly?
*
Signature
*
Submit
Should be Empty: