Tutoring Registration 2018 - 2019
All sections must be filled out.
Student's Full Legal Name *
Your answer
Student's Preferred Name
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's email *
Put n/a if not applicable
Your answer
Student Phone Number *
Put n/a if not applicable
Your answer
Name of Primary Contact Parent/Guardian *
Your answer
Relation to student *
Your answer
Primary Contact email *
Your answer
Primary Contact Preferred Phone Number *
Your answer
Type of Phone
Primary Contact Alternative Phone Number
Your answer
Alt. Type of Phone
Second Contact Parent/Guardian
Your answer
Second Contact Relation to student
Your answer
Second Contact email
Your answer
Second Contact Preferred Phone Number
Your answer
Second Contact Type of Phone
Second Contact Alternative Phone Number
Your answer
Type of Phone - Alt.
Home Address(es) *
Your answer
Emergency Medical Information
Your answer
Emergency Contact if Parents are Unavailable *
List at least one person and their phone number.
Your answer
Person(s) Responsible for Billing *
Your answer
Billing Contact's Phone Number *
Your answer
Choose a Billing Option for Invoices *
**Quarterly invoices are sent out every three months and cover Sept - Nov, Dec - Feb, Mar - May, and June
Choose a Billing Type for Invoices *
Email or Mailing Address for Invoices *
Your answer
Grade for School Year 2018 - 2019 *
Name of School Student is Currently Attending *
Your answer
Subject(s) needing tutorial support. *
Your answer
List the number of tutoring sessions per week and day/time requests. *
Your answer
Preferred Start Date *
MM
/
DD
/
YYYY
Teacher/Tutor Preference
List first, second, and third choices if known.
Your answer
Will student need Privett van transportation from Privett to MIHS in the morning or from MIHS to Privett in the afternoon? *
If you answered yes to the previous question, please complete and return a transportation permission form found at the link below.
By submitting this form, you acknowledge that all information provided is accurate and agree to The Privett Academy's Fees & Policies.
The following is required before a student can be scheduled and services can be provided:
*Tutoring Registration Form
*Transportation Permission Slip (for students taking the van)
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.