Academics Plus, Inc. Student Information
Student Name *
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Parent/Guardian Name *
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Street Address *
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City State Zip Code *
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Best telephone contact number *
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Alternate telephone contact number
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Email Address
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What school does your child attend?
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Grade Placement *
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Is your child currently passing their grade?
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Has your child ever repeated a grade in school? If yes, which grade.
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Describe the area(s) where your child needs tutoring support?
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Describe any special services your child may get at school? For example: Reading Support, Special Education, Speech
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List any medical conditions which have been diagnosed by a health or educational provided. For example: ADHD, Behavior Disorders, Autism, Diabetes, Seizures, or others
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Name(s) of medications your child takes to support overall health and learning behavior.
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Select the time and days on which you would like tutoring.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
3:00 - 4:00 p.m.
4:00 - 5:00 p.m.
5:00 - 6:00 p.m.
Our services are provided in home. Please identify a location where you would like tutoring to occur.
After completing and submitting this information, I understand that all information is confidential and will not be shared except as needed to assist the tutor with preparation for tutoring my child. *
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