You must have JavaScript enabled to use this form. 1 Start 2 Page 2 3 Page 3 4 Page 4 5 Complete Select up to four choices Course Selection * Intensive Reading Intensive Math Reading Support Math Support Homework Help Social Emotional Learning (K-8 Only) Credit Recovery (9-12 Only) Student information (please enroll only one student at a time. Complete additional form for each additional child enrolled): Student Name/Grade/School Name 1. Student Name * 2. Student Gender: * Male Female Rather Not Say Other... 2. Student Gender: Other... 3. Grade * Pre-K K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 4. School Name * 5. Medium of Regular School Instruction * in person blended online homeschool 6. Disability Status * Yes No If yes, please describe If yes, include IEP goals: 7. Preferred Method of Contact/Permission * Call Text Email Parent/Guardian Contact Info (Primary) 8. Name (Primary) * 9. Phone Number (Primary) * Please enter your phone number in the designated format with numbers and dashes (e.g. 555-555-5555) 10. Email (Primary) * 11. Cell Phone Provider (Primary) * AT&T Verizon Sprint T-Mobile Cricket Wireless Metro PCS Other... 11. Cell Phone Provider (Primary) Other... Parent/Guardian Contact Info (Secondary) 12. Name (Secondary) 13. Phone Number (Secondary) 14. Email (Secondary) 15. Cell Phone Provider (Secondary) AT&T Verizon Sprint T-Mobile Cricket Wireless Metro PCS Other... 15. Cell Phone Provider (Secondary) Other... Student contact info (usable by student) 16. Name 17. Phone number (if applicable) 18. Email (if applicable) 19. Devices Available for Use (Select all that Apply) * Phone Laptop PC Tablet Printer 20. Programs/Applications Used/Approved for Student use during Tutoring * Microsoft Office Google Classroom YouTube Other... 20. Programs/Applications Used/Approved for Student use during Tutoring Other... Leave this field blank