Full Name

Age

Grade

Email Address

Phone Number

City

State

Current School Name

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Phone Number

Subjects Needing Help With Subjects Needing Help With Reading Writing Language Math

How Often Would You Like Tutoring? How Often Would You Like Tutoring? 1x/week 2x/week 3x/week 4x/week 5x/week As needed

Preferred Tutoring Format Preferred Tutoring Format In-Person Online Either

Do You Have Access to a Computer & Internet for Online Tutoring? (Yes/No) Do You Have Access to a Computer & Internet for Online Tutoring? (Yes/No) Yes No

Have You Had a Tutor Before? Have You Had a Tutor Before? Yes No

What worked or didn’t?

What Are You Struggling With?

What Are Your Academic Goals? (e.g., improve grades, prep for a test, feel more confident)

What Are Your Hobbies or Interests?

Any Additional Information You'd Like to Share?

How Did You Hear About Us?

I have permission from my parent/guardian to apply for a tutor. I have permission from my parent/guardian to apply for a tutor. I have permission from my parent/guardian to apply for a tutor.

I confirm that the above information is accurate I confirm that the above information is accurate I have permission from my parent/guardian to apply for a tutor.