Tutoring Registration 2019 - 2020
All sections must be filled out.
Student's Full Legal Name *
Student's Preferred Name
Student's Date of Birth *
Student's email *
Put n/a if not applicable
Student Phone Number *
Put n/a if not applicable
Name of Primary Contact Parent/Guardian *
Relation to student *
Primary Contact email *
Primary Contact Preferred Phone Number *
Type of Phone
Primary Contact Alternative Phone Number
Alt. Type of Phone
Second Contact Parent/Guardian
Second Contact Relation to student
Second Contact email
Second Contact Preferred Phone Number
Second Contact Type of Phone
Second Contact Alternative Phone Number
Type of Phone - Alt.
Home Address(es) *
Emergency Medical Information
Emergency Contact if Parents are Unavailable *
List at least one person and their phone number.
Person(s) Responsible for Billing *
Billing Contact's Phone Number *
Choose a Billing Option for Invoices *
**Quarterly invoices are sent out every three months and cover Sept - Nov, Dec - Feb, Mar - May, and June
Email Address for Invoices *
Grade for School Year 2019 - 2020 *
Name of School Student is Currently Attending *
Subject(s) needing tutorial support. *
List the number of tutoring sessions per week and day/time requests. *
Preferred Start Date *
Teacher/Tutor Preference
List first, second, and third choices if known.
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)
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