Enrollment Form | Redefined Teaching Tutoring Services

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Student Enrollment Form

Child's first name(Required)

Child's last name(Required)

Gender(Required)

Current Grade Level(Required)

Birthday

Month

Day

Year

Current School

Mother/Guardian Name(Required)

Address

Cell Phone Number(Required)

Home Phone Number(Required)

Work Phone Number(Required)

Father/Guardian Name

Address

Cell Phone Number

Work Phone Number

Subjects Needing Support(Required)

Reading

Math

Writing

Science

Test Prep

Other Parent Concerns(Required)

Academic

Confidence

Focus

Homework

Behind

TutorPlan Selected(Required)

Academy Recovery

Academic Recovery Extended

Academic Momentum

Report Card Rescue

Format(Required)

In-person preferred

Virtual preferred

Medical Information Allergies/Concerns(Required)

Medications

I authorize the following individuals to pick up my child from the tutoring program. I understand that my child will only be released to the individuals listed below, unless I provide written notice of changes.

Name(Required)

Relationship to the Child(Required)

Phone(Required)

Name(Required)

Relationship to the Child(Required)

Phone(Required)

Emergency Contact (If different from parent/guardian):

Name

Relationship to the child

Phone

Important Notes:

A valid photo ID may be required at the time of pick-up. The program reserves the right to refuse release of a child if proper identification is not provided.

Changes to authorized personnel must be submitted in writing.

How Did You Hear About Us?

Referral

Social Media

School

Online

Other

Full Name of Signee(Required)

I agree to tutoring terms, payment policies, and participation requirements. (Required)

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