Intake Form
Welcome to Significant Educators! We're excited to learn more about your child so we can tailor our tutoring services to their unique needs. Please take a few moments to fill out this form, which will help us better understand how to support your child's academic and emotional growth. 
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Title *
Mr. & Mrs., Mrs., etc.
First Name(s) *
Last Name *
Email *
Additional Email *
Mobile Phone *
Work Phone
Address *
Address 2 (Apt)
City *
State *
Zip/Postal Code *
Country *
Student First Name(s) *
Student Last Name *
Student Email
Student Cell Phone (teens only for scheduling purposes)
Student Birth date *
MM
/
DD
/
YYYY
Student School *
Grade/Year *
Type of support requested *
Which package(s) might you be interested in? *
Required
Who will be responsible for scheduling sessions? *
Required
Subject Needing Support 1 *
Subject Needing Support 2 (if applicable)
Current Overall Grade in Subject 1  *
Current Overall Grade in Subject 2 (if applicable) *
Teacher Name for Subject 1 *
Teacher Name for Subject 2 (if applicable)
Relationship with Teacher of Subject 1  *
Liver and Brussel Sprouts
Pizza and Ice Cream
Relationship with Teacher of Subject 2 (if applicable)
Liver and Brussel Sprouts
Pizza and Ice Cream
Clear selection
Level of Independence in handing in schoolwork and academic responsibilities. *
Needs GPS to find their HW
Master of HW - Fu, can juggle textbooks blindfolded
Level of Studying for a big test. *
Cramming the night before, fueled by caffeine/chocolate and sheer panic
Studying a week ahead, like a kung fu master preparing for a tournament, striking first and striking hard
What are your goals and students goals for the sessions? *
Please briefly summarize your child's strengths (academic and emotionally) *
Please briefly summarize your child's academic challenges. In addition, if applicable, please describe any emotional or social challenges your child may be facing.  *
Does your child have any neurodiverse needs we should be aware of?  *
Required
Type of Session *
Most of our sessions are online. In - Person sessions are available in the following counties and for limited subjects: NY: Erie, Nassau, Suffolk, Westchester | CT: Fairfield | CA: Los Angeles [Inquire about other areas as our team is slowing growing - As we value quality over quantity]
Preferred Schedule
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8AM - 12 PM (Saturday/Sundays Only) EST
2:30 PM - 5:00 PM EST
5:00 PM -11:00 PM EST
I understand that an adult (parent, nanny or babysitter) must be present in the home during all in-person sessions.  *
Do you expect a change in schedule mid-year (i.e. sports schedule change)?
Additional Family Information  *
Understanding a little bit about your family can help our tutors build rapport with your child.  Please let us know if there is any information that may help us. (i.e. sibling name and age)
Supplementary Educational Information *
Please use this space to provide any supplementary information that you think would be beneficial for the tutor to know. This could include details about the student's interests, learning style, or any specific accommodations they may require. 

Do you agree to the following terms?

Marketing: Significant Educators may use anonymized data and feedback from the tutoring sessions for marketing and promotional purposes. No personal or identifying information will be disclosed without your explicit consent. If you do not wish to have any data used for marketing purposes, please notify Significant Educators in writing. We respect your privacy and are committed to protecting your personal information. We will never share, sell, or distribute your email address or any other personal information to third parties.

Email: You agree to receive email marketing communications from Significant Educators. You can opt-out of receiving these emails at any time by following the unsubscribe instructions included in the emails.

Cancellation Policy: As our availability is extremely limited, we require 24-hour cancellation notice (unless there is an emergency). If proper notice is not given, the full session rate will be charged. Additionally, if two cancellations occur without proper notice, the session rate will be transferred to the non-weekly rate. *
Who can we thank for the referral?
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