K-12 Student Enrollment Form

Date*

Student First Name*

Student Last Name*

Student Date of Birth*

Current Grade Level*

Current School*

Student Gender*

Student Ethnicity

If multiple/Other, specify

Are you of Hispanic or Latino/a origin? (if not selected above)

Main/Physical Address *

Mailing Address (if different)

Student Email

Parent/Guardian #1 First Name*

Parent/Guardian #1 Last Name*

Parent/Guardian #1 Phone*

Parent/Guardian #1 Work Phone

Parent/Guardian #1 Email*

Parent/Guardian #2 Name*

Parent/Guardian #2 Phone

Parent/Guardian #2 Work Phone

Parent/Guardian #2 Email

Phone to Call First in Emergency*

What subject does your student need help with?*

Math

Reading

Writing

ACT/SAT Prep

Science

Social Studies/History/Civics

GED - Referred from High School

Foreign Language

Other

Does student REQUIRE a Spanish speaking tutor?*

Is there an IEP or 504 Plan in place?*

Describe what the student needs help with in more detail*

List student's strength(s)*

List special interests and hobbies*

Anything else you'd like to share

Days of the week available*

Monday

Tuesday

Wednesday

Thursday

Friday

Times available*

9:00 AM

10:00 AM

11:00 AM

Noon

1:00 PM

2:00 PM

3:30 PM

4:30 PM

Sessions desired per week*

Release of Student Records consent*

Photograph and Video Release*

Yes*

Yes*

Submit