Student Application For Tutoring

Student Name Date of Birth Grade

Parent/Guardian Address

Phone # -- Email

Special Needs  YesNo

Please specify all areas in which student needs tutoring
Reading   Math   Writing   Comprehension   

Give details on specific area need

Parent Consent for tutoring
(NOTE: This consent means the parent takes responsibility to have the student attend tutoring sessions as scheduled)

Has student had tutoring before? YesNo  Describe

Have there been behavior problems in school?  YesNo  Describe

Name student´s most difficult subject

Name favorite subject

List some of student´s hobbies

When not in school, what are student's favorite activities?

Does student have problems with Homework? YesNo   If Yes, explain

Do teachers give the student extra help? YesNo   If Yes, explain

1. Monday ­ Friday
   3pm ­ 6pm - $50.00 per 3 hour session
   (1 hour sessions $17.00)
2. Saturday
   11:00am ­ 2:00pm $50.00
   2:00pm ­ 5:00pm $50.00
   (1 hour sessions $20.00)
   **Sunday Hours are available at higher rates
3. Special Pricing for weekday after school homework assistance with tutoring
   Monday ­Friday 3-6pm $75.00 per week with contract and monthly payment.

Please specify your plan Plan A Plan B Plan C

If you choose Plan A or B, please specify your schedule below:
Monday From:       To:
Tuesday From:       To:
Wednesday From: To:
Thursday From:      To:
Friday From:          To:
Saturday From:      To:

First payment due at first session

Parent Initial for consent

When you click submit and your application has been successfully submitted and you will be re-directed to the Home Page.