Application for Tutoring/Executive Function Skill Building Services

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

Thank you for your interest in tutoring and/or Executive Function Skill Building at LDA Minnesota! Please answer the following questions to give us some more information about your needs.

If you have any documentation to share with LDA prior to starting services (such as an IEP, 504 Plan, other accommodation plan, etc.) please email it to tutoring@ldaminnesota.org, fax it to 952-582-6031, or mail it to 6100 Golden Valley Rd, Golden Valley, MN 55422.

Please call us at 952-582-6000 with any questions.

Email *

Student's Name *

Application Date *

YYYY

Student's Date of Birth *

YYYY

Student's Gender *

Female

Male

Prefer not to say

Non-binary or Agender

Other:

Student's Age *

Student's Grade (if applicable)

Parent/Guardian Name (if applicable)

Current Street Address *

City, State, and Zip *

Preferred Phone Number *

Preferred Method of Contact *

Phone

Program for which you are applying *

1:1 Tutoring ($75/hour or $67.50/hour for 12 prepaid sessions)

1:1 Executive Function Skill Building ($75/hour or $67.50/hour for 12 prepaid sessions)

Executive Function Workshop - Small Group Session - ($340/6 hours) Please see website for current scheule.

Required

Clear form

Never submit passwords through Google Forms.

This form was created inside of LDA Minnesota.

Does this form look suspicious? Report

Forms