Private Tutorial Sessions
Email address *
General Tutoring
• Extra support and accountability for regular classroom work/assignments/homework
• Additional time and support for concepts taught in the classroom
• Higher level of support and accountability for learning
• An intentional approach with multi-sensory techniques
• Remedial instruction for gap areas in learning (tutoring goals to be established)
Date: *
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Tutoring Start Date:
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YYYY
Student Name: *
Your answer
Student Age: *
Your answer
Student Birthday:
Your answer
Student Grade: *
Your answer
School: *
Your answer
School District: *
Your answer
Parent Name: *
Your answer
Parent Email: *
Your answer
Home Phone:
Your answer
Mobile Phone: *
Your answer
Student may be released to:
Your answer
Does your child have an IEP, 504, and/or RTI?
What subject(s) areas does your child need tutoring ? *
Your answer
Please indicate any specific areas of concerns that need to be address in tutoring.
Your answer
Please list day(s) and time(s) preferences.
Your answer
Are you interested in having tutoring for the entire school year? *
If not, how many lessons would you like for your child?
Your answer
Do you plan to continue services in the summer? (next grade-level preview/enrichment)
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