Student Information Form
Please complete this form so that we will have all of your contact information on file.
Student's info:
What is your student's first name? *
Your answer
What is your student's last name? *
Your answer
Please explain why your student needs tutoring: *
Your answer
So we can get to know them better, what are some of their interests? *
Your answer
What is your student's birthday? *
Format: (1/2/07)
Your answer
Parent/Guardian's info:
What are the student's parent/guardian's first name/s? *
Your answer
What are the student's parent/guardian's last name/s? *
Your answer
What is your primary Email address? *
Your answer
What is your backup #2 Email address?
(Only if you have an additional Email)
Your answer
What is your backup #3 Email address?
(Only if you have an additional Email)
Your answer
What is your first cell phone number? (format= 540-555-1234) *
This is the number that all tutoring session TEXT/SMS reminders will be sent to.
Your answer
Cell phone #1 contact name:
Your answer
Who is your cell phone provider? *
This is required to be able to send you TEXT/SMS reminders about your tutoring sessions
What is your home phone number? (format= 540-555-1234)
Your answer
What is your work phone number? (format= 540-555-1234)
Your answer
What is a second cell phone number? (format= 540-555-1234)
Your answer
Cell phone #2 contact name:
Your answer
What is a third cell phone number? (format= 540-555-1234)
Your answer
Cell phone #3 contact name:
Your answer
Who should we contact in case of emergency and we can not reach you at the above numbers? *
Your answer
What is their phone number? *
Your answer
Names of people authorized to pick up your child: *
Use can put that student will be driving themselves.
Your answer
What is the best way/time to contact you? *
Your answer
Home address:
Street
Your answer
City
Your answer
State
Your answer
Zip
Your answer
How did you hear about us? *
If referred by someone or you chose other, please describe who/what:
Your answer
Any additional information you would like to share with us:
Your answer
Medical Information:
Does your child have any food allergies? *
Please put N/A if there are not any allergies.
Your answer
Is there any relevant medical information we should be aware of? *
Please put N/A if there isn't anything.
Your answer
School Information:
What grade is your student currently in? *
Your answer
What school is your student currently attending? *
Your answer
What county is the school in? *
Your answer
What is your student's teacher/s name/s?
Your answer
Does your child have an IEP or 504 plan? *
If yes, please explain:
Your answer
Testing information:
(If applicable)
Math SOL score:
Your answer
Reading SOL score:
Your answer
Other Subject SOL scores:
Your answer
SAT Scores:
Your answer
ACT Scores:
Your answer
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This form was created inside of Parrish Learning Zone, LLC.