New Student Registration

Tutoring Student Registration Form

Student's Name

First

Last

Date of Birth

Gender

What grade is the Student in?

What level is the Student?

Parent/Guardian Name

Parent/Guardian Email

Address

Address 2

City

State

Zipcode

Allergies or Health Concerns?

Date Student? to

Student E-mail

What would you like me to know about your child?

Parent/Guardian Name

First

Last

Parent/Guardian Phone

Parent/Guardian Email

Emergency Contact

First

Last

Relationship to Child?

Emergency Contact #

Permission & Agreement

I give the student stated here permission to attend this tutoring program pursuant to all the terms and regulations that apply.