Service & Payment Plan*

Dec ACT 11 Week Session

Price

$1,499.00

Guardian First Name*

Guardian Last Name*

Guardian Email*

Guardian Phone Number*

Student First Name*

Student Last Name*

Student Email*

Student Phone Number*

Address*

Student High School*

Graduation Year*

What are the student's pronouns?*

Completed Math courses (select all that apply)*

Geometry

Algebra 2

Precalculus

Calculus

If already decided, which test is the student planning to take?*

ACT

SAT

Not sure

Does the student receive accommodations in school (IEP, 504, etc.)*

Yes

No

Not sure

Please enter any previous official test scores (include month and year of test)*

Is there anything else you think we should know?

Please list any siblings and their graduation years.

How did you hear about us?*

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I agree to receive appointment confirmations, reminders, and other information from Pollak Tutors

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I understand and agree to be charged for an appointment if not cancelled within 24 hrs. of the scheduled time

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I understand all classrooms are monitored by video for safety and training purposes.

Payment Information*

Payment amount:

$1,499.00

Total to pay:

$1,499.00

Signature*

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