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New Student Registration
Student Information:
Student Name
*
First
Last
Grade Level
*
Twelfth Grade
Eleventh Grade
Tenth Grade
Ninth Grade
Eighth Grade
Seventh Grade
Sixth Grade
Fifth Grade
Fourth Grade
Third Grade
Second Grade
First Grade
Kindergarten
Student Phone (optional)
*
Would you like to receive text reminders?
*
Yes
No
Student Email Address (if applicable)
*
Area(s) you'd like to focus on in your sessions:
*
Math
Reading
Writing
Science
Social Science
Foreign Language
Organization & Study Skills
Homework Help
Test Preparation
Academic Enrichment
App Development (Coding)
Other
Favorite Subjects
*
Least Favorite Subjects
*
What grades did you earn in the last grading period?
*
School Name:
*
Birthday (Month/Day/Year)
*
Choose One
*
Male
Female
Names & ages (or grades) of siblings
*
Do you prefer a male or female tutor?
*
No preference
Male
Female
About how often would you like to meet?
*
One session per week
Two sessions per week
Three sessions per week
Four or more sessions per week
Other
Frequency of sessions can be changed at any time.
Desired Days/Times for Sessions
*
Activities and interests outside of school
*
Any upcoming test dates we should know about?
*
What do you hope to earn in the next grading period?
*
Parent Information:
Parent Name
*
First
Last
Additional Parent Name (optional)
*
First
Last
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Additional Phone Number
*
Additional Email
*
Referred by:
*
Friend or Classmate
Teacher or School Administrator
Charity Auction or Raffle
KCRW Fringe Benefits Program
Decoding Admissions
Internet Search
Advertisement
Other
Anything else we should know?
*
Electronic Signature
*
I have read and agree to the terms and conditions outlined in the Client Agreement.
Submit Registration
Our Clients
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FAQ
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