Child's Name *

First Name

Last Name

Child's Birthday

MM

DD

YYYY

Main Point of Contact *

Parent/Guardian's Name

First Name

Last Name

*

Parent/Guardian's Phone Number

(###)

###

####

Topics you would like us to focus on, select all that apply. Note that we will need to complete at least one evaluation for literacy topics, and one evaluation for math topics if you select multiple areas of focus.

Reading Fluency

Reading Comprehension

Spelling

Writing

Handwriting

Singapore Math Curriculum

Mental Math

Math Story Problems

Standardized Testing Prep

All of the Above

Only Supporting Classroom Math Work (teacher guidance required)

Do you read with your child every night before bed?

Yes

No

Often

Inconsistently

Would you like your child's tutoring program to include age-appropriate reinforcement work?

Yes

No

Maybe

Sometimes

How did you hear about us? Who may we thank?!

Social Media Post

Website

Google Search

Referral