LFAL Logo.jpg Learn for a Lifetime Intake Packet

Dear Parent or Guardian,

Thank you for your interest in Learn for a Lifetime and congratulations on taking the first step to helping your student. This packet will give you all the information that you need to make the right choice for you and your family. Included you will find information on all of our services, pricing, contact information and the required paperwork if you should decide that we are the right program for your student.

Tutors at Learn for a Lifetime are available by appointment 8am to 7pm Monday through Saturday. We will call you to set up individual services based on your schedule.

Tutors are available to meet your student in your home, at our office, or at school. Meeting in the school is dependent on permission from the principal and teacher. We also offer Skype/Facetime sessions, home school help, and assistance for home and hospital bound students.

At Learn for a Lifetime we believe in being involved. We would like to get to know your student, you, your student’s teacher(s), and school. With your permission, your student’s tutor will observe in the classroom and get detailed information from the teacher regarding your student’s needs. We are also interested in any diagnoses or IEPs that you would like to share. All information will be confidential.

For more specific information please view our website at www.learnforalifetimelc.com. You should also feel free to call us at 575-208-6395.

Thank you!

Jodi Starnes

Jodi Starnes

Owner

LFAL Logo.jpg Learn for a Lifetime  Intake Packet

Policy Statement:

Scheduling:

Learn for a Lifetime offers tutoring in your home, our office, and your student’s school, at your convenience. If your student misses session, needs to cancel, or wants to schedule/reschedule, please call the office. Tutors are not obligated to give out their personal number. If you and your tutor change your schedule, please call the office to confirm with Jodi.

Cancellations:

Learn for a Lifetime has a 24 hour cancellation policy. Clients will be charged for any missed sessions. Clients will also be charged for sessions that are not canceled 24 hours in advance. All sessions will end at the scheduled time, regardless of when the client shows up. This allows the tutors to meet their next client on time.

Payment:

Payments are to be made at the beginning of each session. If you previously missed a session, you will also need to pay that fee at the beginning of your next scheduled session. Students who are not up to date on payment will not be seen. Learn for a Lifetime accepts cash, checks, or credit/debit cards. Learn for a Lifetime strives to help every student no matter the financial situation. If you are in need of assistance, please don’t hesitate to ask.

Taxes:

Learn for a Lifetime charges tax.
Tuition, including tax, will be as follows:

Home School Sessions: $16.25

Office Sessions: $27.08

School/Daycare/Facetime/Skype Sessions: $37.91

Home Sessions: $48.74

Confidentiality:

All paperwork and content during sessions will be held confidential. Learn for a Lifetime will not reveal the names of clients or discuss clients with anyone. We will discuss client information with teachers, as requested by the parent. Tutors and the owner may discuss information to create goals for students as needed.

LFAL Logo.jpg Learn for a Lifetime  Intake Packet Client Information

Student Information:

Last Name:______________________________

First Name:_____________________________

DOB:____________________ Age:______________

Grade Level:____________________

Parent or Guardian Information:

Last Name:______________________________

First Name:______________________________

Cell Phone Number:_______________________

Work/Home Phone Number:_________________

E-mail Address:___________________________________________

Mailing Address:__________________________________________

Last Name:______________________________

First Name:______________________________

Cell Phone Number:_______________________

Work/Home Phone Number:_________________

E-mail Address:_____________________________________

Mailing Address:____________________________________

School Information:

School Name:______________________________________

School Address:_____________________________________

Principal’s Name:______________________________
School Phone Number:________________

LFAL Logo.jpg Learn for a Lifetime  Intake Packet Emergency Contact Information:

(For in-office students only)

Medical Information and Release

Please list any allergies or medical conditions your student has:__________________________________

__________________________________________________________________________________________________________________________________________________________________________

Hospital of Choice:_____________________________________________
Learn for a Lifetime has permission to make medical decisions for _______________________________ in the absence of ___________________________________________________________. Signature:________________________________________ Date:___________________________

Authorized Pick-Ups

1) Name:____________________________________________________

Cell Phone Number:_____________________

Work Phone Number:___________________

2) Name:____________________________________________________

Cell Phone Number:_____________________

Work Phone Number:___________________

3) Name:____________________________________________________

Cell Phone Number:_____________________

Work Phone Number:___________________

LFAL Logo.jpgLearn for a Lifetime  Intake Packet

Parent Questionnaire:

Student Name:______________________________
Grade Level:___________________________

What subject(s) do you feel your student needs help in? __________________________________________________________

__________________________________________________________

Would you like a tutor to help your student with homework?___________

Please list specific skills you would like your student to work on:_________________________________________________________

________________________________________________________________________________________________________________________

Would you like a tutor to observe your student in the classroom?________

Would you like a tutor to speak with your student’s teacher(s)?__________

If yes, please list which teacher(s):_______________________________________________________________________________________________________________

Are there any learning challenges or diagnoses that you would like to share?______________________________________________________

________________________________________________________________________________________________________________________

Please attach an IEP if you have one. All information that you share with Learn for a Lifetime is confidential. Only the owner and your student’s tutor will see this information.

Please give us any additional information that you feel would be helpful for your student’s tutor to know:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LFAL Logo.jpg Learn for a Lifetime  Intake Packet Photography Release

Please select ONE:

_____ Learn for a Lifetime has permission to photograph my child for use in class projects or to release to parents. These photographs will not be used in any public format or released to anyone besides parents.

_____ Learn for a Lifetime has permission to photograph my child for use on Facebook and the Learn for a Lifetime website, as well as class projects or to release to parents.

____ Learn for a Lifetime DOES NOT have permission to take photographs of my child for any purpose.

In signing below, I acknowledge that I provided accurate information to Learn for a Lifetime. If any information should change, I will immediately provide that information to Learn for a Lifetime. I furthermore have read and understand all policies and included information. My signature grants medical release and photography release as indicated.

Parent/Guardian Signature:

___________________________________________
Date: ___________

Jodi Starnes Signature:

___________________________________________ Date: ___________

LFAL Logo.jpg Learn for a Lifetime  Intake Packet

Teacher Questionnaire:

(Feel free to make copies as needed)

Student Name:______________________________
Grade Level:___________________________

Teacher Name:_______________________________________

Teacher E-mail:_______________________________________
Teacher Phone Number:________________________________

What subject(s) do you teach this student?_____________________________________________
________________________________________________________________________________________________________

What specific skills do you feel this student needs help with?________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Will you allow a tutor to observe this student during your class?__________

If yes, what time is this student in your class?____________

Signature:________________________________________
Date:___________________________