Client Intake Form Homework Helpers Marin

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the following survey so that we can best understand you and your needs

Email *

Student's Name *

Parent 1 Name *

Relationship to Student *

Parent 1 Cell Phone Number *

Parent 2 Name

Relationship to student

Parent 2 Cell Phone Number

Parent 2 Email

Student Grade Level (K-12) *

School Student Currently Attends *

Student Street Address *

Student City and Zip Code *

I agree to pay Homework Helpers Marin for services provided within one week of receiving invoice/payment request - please enter you electronic signature below *

Please write your name below if you agree to this statement: I understand that the standard rate for a Homework Helpers of Marin Academic Coach is $60/hr. Rates do vary depending on frequency and the needs and level of academic support needed by each student. *

Tell us why you have contacted Homework Helpers Marin:

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms