Registration for the 2018-2019 School Year
Rate is $110 per hour and $60 per 1/2 hour session.
Primary Parent Name *
(Last, First)
Your answer
Primary Parent Cell Number *
Your answer
Primary Parent Email Address *
Your answer
Secondary Parent Name
(Last, First)
Your answer
Secondary Parent Cell Number
Your answer
Secondary Parent Email Address
Your answer
Home Address *
Your answer
City *
Your answer
Zipcode *
Your answer
Student #1 Name *
Your answer
Student #1 Cell Number
Your answer
Student #1 Email Address
Your answer
Student #1 Math Course - Instructor's Name - School
Ex: Algebra 1 Pre AP - Mrs. Smith - TWHS Main Campus
Your answer
Student #2 Name
Your answer
Student #2 Cell Number
Your answer
Student #2 Email Address
Your answer
Student #2 Math Course - Instructor's Name - School
Ex: Algebra 1 Pre AP - Mrs. Smith - TWHS Main Campus
Your answer
Student #3 Name
Your answer
Student #3 Cell Number
Your answer
Student #3 Email Address
Your answer
Student #3 Math Course - Instructor's Name - School
Ex: Algebra 1 Pre AP - Mrs. Smith - TWHS Main Campus
Your answer
How often would the student like to meet with me? *
Please note: If the student has completed all assigned classwork prior to our meeting, we will work ahead or review ACT/SAT materials during Pre-Scheduled Weekly Appointments.
Desired Time Slots *
Please provide several options. Please choose from Monday-Thursday 12:00pm-7:00pm (beginning at noon and ending by 7:00pm). Other days and time may be possible. Rate is $110 per 1 hour and $60 per 1/2 hour.
Your answer
Summer Sessions *
For students who wish to prepare ahead, study for the ACT/SAT, learn how to factor polynomials properly, etc.
Cell Number for Text Messages *
Please provide the preferred cell number(s) to receive text messages. This is the main form of communication that I use for scheduling and appointment reminders.
Your answer
Mass Text Message List
Would you liked to be placed on a mass text list for any one time cancellations that may open up at the last minute? The first person to respond will receive the slot. You may opt-out at anytime.
Cancellation Fee *
I understand that a STRICT 24 hour cancellation notice is required. Only the first last-minute cancellation will be waived per student per school year. Subsequent cancellations will require full payment. Rate is $110 per 1 hour and $60 per 1/2 hour.
Terms of Service *
I understand the all handouts and information are proprietary and WILL NOT be shared or sold to others. Excessive cancellations or rescheduling (i.e. 2 or more per month) may result in the loss of a permanent regular appointment.
Please provide any additional comments or questions below.
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Residential Speed Limit 20 mph *
Location, Parking and Restroom Information *
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Whom may I thank for the referral?
(Name, Google, etc.)
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