Enrollment Form
Email *
Parent/ Guardian Name *
Parent/ Guardian Phone Number *
Parent/ Guardian Email Address *
Full Address *
Child 1: Name/ Grade *
Child 2: Name/ Grade
Area(s) of concern
Reading
Writing
Spelling
Child 1
Child 2
Desired number of tutoring sessions per week.
1
2
3
Child 1
Child 2
Clear selection
Desired day(s)/time(s) for tutoring. 
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
7am-8am
8am-9am
9am-10am
10am-11am
11am-12pm
12pm-1pm
1pm-2pm
2pm-3pm
3pm-4pm
4pm-5pm
5pm-6pm
7pm-8pm
Desired start date. *
MM
/
DD
/
YYYY
Any additional information?
Promo Code
A copy of your responses will be emailed to .
Submit
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