Tutoring Program Enrollment Form

Tutoring Program Enrollment Form
Date*

MonthDayYear
Student's Name*

First NameLast Name
Student's Age*
Student's Date of Birth*
Name of Parent/Guardian*
Home Address*
City, State, ZIpcode*
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
E-mail*
Student's Grade (i.e. 5th, 6th)*
Student's Current Grade in Class (i.e. A, B, C+)*
Which subject matter does the student need assistance with?*
Which special services does your child receive at school?*
Test Prep:

SATASVABACTPRAXIS (math only)
Any medical diagnosis that affect the student's learning?*
How does the student learn best? Any suggestions for their tutor?*
Preferred Time Window for Tutoring*
Best Days for Tutoring?*
Electronic signatures are required. Please use the computer mouse, or your finger (if using tablet, laptop, or phone) to complete.
Clear
Student Signature if older than 18 years of age
Clear
Parent/Guardian Signature
Responsible Party's Name:*

First NameLast Name
By e-signing above, you acknowlegde that you agree to be paired with a EduFusion Institute tutor for a tutoring session. No payments are paid to tutors. If you have any questions or comments concerning the services you recieve please contact the EduFusion Institute directly at (240)716-9536 ext.3
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