REGISTRATION
Accelerating Student Achievement Across America
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Program(s) Programs you wish join check all that apply
Parent names (mother & father) , email, phone number (work & home)
Student First Name
Student Last Name
Student Phone number
Student email
Grade Level
Age
Home Address City, State, Zip Code
Current School ( Name & Address)
Time Zone
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Subject(s) you need help with, check all that apply
Preferred Help Schedule (check all that apply)
Current Grades in difficult subjects. ** Please answer honestly, it's important because it tells us how much support you may need. We are here to HELP you, not judge you!! We believe in YOU!!!!
Check All That Apply
How did you learn about EYM?
Do you have a computer with a web camera?
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Do you have internet at home?
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Does this student participate in a free lunch program?
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Total number of people in the student household?
Number of siblings?
Emergency Contact: Name, phone, number & email.
Tell us something about yourself. What are your goals and interest?
Student's Nationality (Optional)
Parent's Nationality (Optional)
By submitting this agreement, you agree EYM reserves they right to terminate tutoring / mentoring sessions if we believe it is not the right fit
A copy of your responses will be emailed to the address you provided.
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