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Student Enrollment Form
Child's first name
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Child's last name
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Gender
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Current Grade Level
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Birthday
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Day
Year
Current School
Mother/Guardian Name
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Address
Cell Phone Number
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Home Phone Number
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Work Phone Number
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Father/Guardian Name
Address
Cell Phone Number
Work Phone Number
Subjects Needing Support
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Reading
Math
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Science
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Other Parent Concerns
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Academic
Confidence
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TutorPlan Selected
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Academy Recovery
Academic Recovery Extended
Mastery Program
Report Card Rescue
If you are enrolling in Report Card Rescue, please submit a copy of the student’s most recent report card along with this application.
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Format
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In-person preferred
Virtual preferred
Medical Information Allergies/Concerns
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Medications
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