Tutoring Registration Form

Student's Name

Parent/Responsible Party

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Phone Number (optional)

(###)

###

####

Parent/Responsible Party Phone Number

(###)

###

####

Parent/Responsible Party Email

Current School and Grade Level

Subject (e.g. ACT/SAT, Geometry, Study Skills)

Tutor's Name (if already scheduled)

Have you already scheduled a session through our office or do you need us to contact you?

Preferred Payment Method

If a credit card is your preferred method of payment, please click the Payment button below after submitting this form.

Preferred Attendance Option

After submitting this form, you will be contacted by our office manager to confirm receipt of your registration and/or to schedule your first session.

Cancellation and Billing Policy - PLEASE READ CAREFULLY We understand that cancellations are occasionally necessary. Because teachers reserve time specifically for your student, please give at least 24 hours notice. Less than 24 hours notice will be subject to charges. No call or no show appointments will be billed in full. By filling out the payment portion of this form, you are leaving your credit card on file and you authorize us to charge your card for any outstanding balance on your account the first week of each month. We thank you for your understanding. Note: We do not take American Express cards at this time.

Electronic Signature

I have read and agree with the terms of this agreement.

Payment