1. Student Information

Full Name (English):

Date of Birth:

Current School:

Grade Level:

Preferred Contact Language:EnglishSpanishKoreanChineseJapaneseOther

2. Parent/Guardian Information

Name:

Relationship to Student:

Phone (Primary):

Phone (Secondary):

Email Address:

Home Address: City: State: ZIP:

3. Academic Goals (Check all that apply)
Current School Curriculum Support (homework help, subject review)Advanced Learning (working ahead of school curriculum)Competition Math (AMC, MathCounts, etc.)Test Preparation (STAAR, SAT, ACT, etc.)Reading/Writing Skills DevelopmentRoboticsEngineeringComputer programming / CodingOther:

4. Scheduling Preference

Preferred Days: MonTueWedThuFriSatSun

Preferred Time(s):

5. Additional Information

Please share any learning concerns, strengths, or special considerations (allergies, learning style, prior tutoring experience, etc.):

Parent/Guardian Signature:
Date: