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Tutoring Registration Form
One-on-one Tutoring for Autistic Students
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Student's Name
*
Your answer
Grade
Your answer
Parent/Guardian Name
*
Your answer
Phone number
*
Your answer
Email address
*
Your answer
Academic Profile - Please check all that apply
*
My child requires academic assistance with homework
My child requires redirection when completing homework (help staying on task)
My child needs academic help (skills-based) in a particular area
My child requires skills-based lessons in math
My child requires skills-based lessons in reading
My child requires skills-based lessons in spelling
My child requires assistance staying on task while practicing reading
My child requires assistance reviewing materials to prepare for tests
My child requires assistance with organization (such as agenda organization and weekly planning for assignments)
Other:
Required
Please describe the academic skills/subjects you would like us to work on with your child
*
Your answer
What is the outcome you would like to see if your child is to participate in this tutoring program?
*
Your answer
Please list any diagnoses (or suspected diagnoses) your child may have which may affect their academic skills
Your answer
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