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Student Name *

Student Email *

Student Number *

Student Gender *

Male Female

Student Age *

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Phone

Current School Name *

Current Grade Level / Year *

What subjects do you need the most support with? (Check all that apply) *

Math Science English/Writing History/Social Studies Test Prep (SAT/ACT/MCAT/Other) Academic Planning; Coursework/College Plan Other:

Goal from Tutoring (Check all that apply) *

Improve grades and subject understanding Build better study habits and time management Prepare for exams and tests (SAT/ACT, CHSPE, etc.) Gain confidence and motivation in learning Other:

Do you prefer in-person or online tutoring? *

In Person Online

What days/times work best for you? *

Do you prefer working with: *

Male Tutor Female Tutor No Preference

How soon would you like to start tutoring? *

ASAP Within a month Later this year Other:

How long do you want this tutoring to last? *

3 months 6 months 1 year 1 year + Not sure Other:

Are you signing up for yourself or your child? *

Myself My Child

Which package will you be signing up for? *

Outlined prices and packages are listed in the Prices/Packages section.

Option 1: 1 Session per Week Option 2: 2 Sessions per Week Semester Package: (3 Months) Annual Package: (Full School Year) Add on: Academic Planning

Method of Payment *

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Student Information

Parent/Guardian (only if under 18)

School Information

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Packages & Payment