Tutoring Enrollment Form

Enrollment Agreement for Tutoring

Today's Date*
MM slash DD slash YYYY
What course do you need help with?*
Student Name*
First Last
Year of Graduation*
Student's grade in Fall 2019*
Student's School*
Parent or Guardian Name*
First Last
Address*
Street Address City State ZIP Code
Parent Cell*
Student Cell
Alternate phone number
Parent Email to receive appointment reminders*
Student's Date of Birth*
MM slash DD slash YYYY
How did you hear about us?*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Authorization*
- A parent must call in cancellations by 8:00 am the day of the appointment
- No shows or last minute cancellations will incur a charge.
- Parents may book and cancel appointments through our on-line system
Photo Release*
From time to time we take pictures of class activities to post on our website or Facebook page. We would appreciate it if you would allow us to use your child's image (no names) without prior consent.
- I agree to allow my child to be photographed for promotional purposes on our website, Facebook page, or printed materials
- No, please contact me for permission before using my child's image
Special Needs*
Please contact an administrator or the teacher prior to the first day of class to discuss any modifications, medications, or special instructions that may help us in working with your child.
Would you like to meet with the Director to discuss your child's academic needs or to make an academic plan? This service is free to all HBA clients.
- Yes, please contact me to set up an appointment.
- No thank you. Not at this time.
CAPTCHA

Tutoring Enrollment Form

Enrollment Agreement for Tutoring

CONTACT US