Application

TRA Tutoring Application

E-mail Address: *

Student's Last Name *

Student's First Name *

Telephone *

Address *

City *

State *

Zip *

Email *

Birthdate * / /

School Grade *

School Name *

Has the student been held back a grade? *

yes
no

Is the student in danger of failing? *

yes
no

Parent/Guardian Last name *

Parent/Guardian First name *

Relationship to student *

Address *

City *

State *

Zip *

Cell Phone *

Other Phone

Other parent/guardian last name

Other parent/guardian First name

Address

City

State and Zip

Phone *

Emergency Contact Last Name *

Emergency Contact First Name *

Address *

City *

State and Zip *

Phone *

What are your academic goals for the student *

Please describe the specific issue that the child needs help with: *

What would the student like to accomplish through tutoring? *

Does the student have difficulties with test taking? For example: math anxiety or concentration. *

Yes
No
Not Sure

Please describe.

Please tell us anything that will ensure a successful learning experience. For example: What subject is the most problematic? Is the child up to grade level in reading? Include anything that will make for a relaxed and comfortable session, such as favorite subject, books, or activities. *

How many hours are you requesting at this time? *

1
2
3
Not Sure

Please select days that the student is available. *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please select which part of day that the student is available More specific times will be arranged later. *

Morning
Afternoon
Evening

Missing sessions without 24 hour prior notice and approval, may result in cancellation . You are responsible for paying your portion, and failure to pay may result in cancellation *

Yes I understand and agree.

Who referred you to this program? *

All information is subject to verification. Please verify that all information is true. *

yes
no

Verification Code: Visual Verification Image

Enter Verification Code: *

* Required