Tutoring Registration
Please Read Parent Information Packet before filling this out.

Contact me with Questions at 2172082062 or at miss.emilystutoring@gmail.com

Email address *
Parent Name *
Your answer
Parent Phone Number
Your answer
Parent Email (Weekly progress reports will be sent) *
Your answer
Child Name *
Your answer
Child Grade *
Your answer
Child School- Needs my vary per district *
Your answer
What subjects would your Child need extra help in? *
Required
What days of the week would you like me to work with your child? *
Your answer
What time would you like me to work with your child? *
Time
:
Include any information you would like me to know about your child. *
Your answer
Does your child have any health issues I should know about Including allergies (Snack will be given.) ? *
Your answer
I would like to pay the following way.
I understand that I will have to pay agreed upon amount per-session and no refunds will be given. *
Required
I give permission for the following people to pick up my child from sessions. *note people may need to show ID *
Your answer
List an Emergency Contact (excluding you) . Include Name and Phone Number. *
Your answer
Parent/Guardian Signature and Date *
Your answer
Tutor Signature and Date
Your answer
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