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SAT/ACT Prep Course Intake Form
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Todays Date: *
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Student Name *
First and last name
Date of Birth *
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Age: *
Home address: *
What school do you attend? *
What grade are you in? *
Gender: *
Student Email: *
Parent Name *
Parent Phone Number *
Parent Email: *
Choose the Following Course(s): *
Required
Do you plan to further your education after high school graduation? *
Required
If yes, will you be choosing: *
Required
Do you know the schools in which you will be applying?   *
Required
 If yes, please name: *
I have taken the SAT prior to taking this course: *
Required
If Yes, what did you score?
Do you have a score that you hope to achieve SAT?   If Yes, what is that score?
I have taken the ACT prior to taking this course: *
Required
If Yes, what did you score?
Do you have a score that you hope to achieve on the ACT?   If Yes, what is that score?
I would rate my overall grades as: *
Required
I consider myself stronger in (check all that apply): *
Required
I consider myself weaker in (check all that apply): *
Required
I consider myself: *
Required
Approximately how many hours per day do you spend on school or community related extracurricular activities?   *
I am participating in this SAT prep course because: *
Required
I am taking this course to raise my score enough to graduate high school. *
Required
Test Dates Scheduled?
SAT
ACT
How did you hear about Breakthroughs of North Florida?
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