Academic Coaching Registration form
We are actively registering students and are glad you have chosen our services.
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Email *
Name of Parent/Guardian: *
Phone number of Parent/Guardian: *
What is the gender of student? *
Ethnicity of the student *
Home Address (# Street, City, State, Zip Code)
Please enter the name of an adult who will monitor your student's academics at home (if different from above). This is who we will contact regarding academic programming. *
Please enter the first and last name of the student you are registering. *
Please enter the current age of student *
Please enter the student's current grade. *
Please enter type of school the student attends. *
Please enter the name of the school the student attends. *
Please enter the name of the school district in which you live. *
Gwen's Girls posts social media events and takes photos. Do you give consent for us to use videos and materials of events that your child may participate in on our website site? *
Does the student have an Individualized Educational Plan (IEP)? *
Does the student receive any additional specialized services that are currently not being implemented such as speech or occupational therapy? *
What level of academic support are you seeking? *
In which subject area(s) would like you like assistance? *
Is there any additional information that you would like to share to help us to meet the needs of the student? *
Gwen's Girls can connect your family with important resources during this stressful time. Would you like someone to contact you discuss any concerns? *
How did you hear about our program? *
A copy of your responses will be emailed to the address you provided.
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