Campaign Survey Form

We are a Seed of Support to Help Students Blossom

Our Support Leads to Success in LITERACY + READING + WRITING + COMMUNICATION
Name*

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
Are you the student, parent, guardian, or representative?*
If you are not the student, what is the student's full name?
What level of education is the student in?*

ElementaryJunior High SchoolHigh SchoolCollegePost GraduateTradeCity Employee continuing education
What is the student's main goal for tutoring?*

Improve gradesTest preparationHomework helpBuild overall confidenceLearn English as a New LanguagePersonal Advancement or Knowledge enrichmentPass a state exam required for career advancementOther
Where do you prefer tutoring? (Check all that apply)*

Remote (Computer, tablet, or phone)In-person (home or library)At school
What time zone is the student in*

CentralPacificEasternAlaskaHawaiiMountain standardOther
Does the student have an individualized learning plan (IEP)*

YesNoIn the evaluation process to get an IEP
What is the student's preferred learning style? (Check all that apply)*

Audio (lecture, recorder, audiobooks)Visual (videos, presentations, photos, etc)Kinesthetic (hands on activities and real world experiences)Unsure but willing to be assessed
What time is preferred for tutoring? (Check all that apply)*

Morning (9:00am to 11:00am)Afternoon (12:00pm to 4:00pm)Evening (5:00pm to 10:00pm)
What days will the student tutor? (Check all that apply)*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
When can the student begin tutoring sessions?*

Immediately (within 24-48 hours)As soon as possible (within 3-5 days)Next month (within 30 days)Eventually (within 2-3 months)Unsure (within 6 months)Other
Literacy Rose Growth specializes in the listed skills. What skill area does the student want to focus on most?

Writing conventions and confidenceReading Comprehension and analysisCommunication and public speakingEnglish language proficiency
Explain the subject area or skill that the student is struggling with
Is there anything else that we should know to best support student? Please explain important information about the student that is relevant to their learning environment
What form of payment do you prefer?*

Credit/DebitZelleCashappPaypal
Please type your name and email below to confirm
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We are a Seed of Support to Help Students Blossom