Student’s Full Name *
Prefered Name (e.g. nickname or shortened name)
Student’s Date of Birth *
Hour or Half Hour Lessons? *HourHalf Hour
In Person or Skype? *In PersonSkype
Weekly Lessons or Ad Hoc? (ad hoc lessons are occasional or every other week) *WeeklyAd Hoc
Student’s Current School/College
Student’s Current School Grade or College Year
Our primary channel of communication is e-mail. Your telephone number is required for emergency contact. Unexpected events may occur which directly affect your scheduled lesson. In cases where e-mail communications may not reach you in time, we would like to be able to call or text you to keep you informed.
E-Mail *
Student’s Cell Phone Number *
Street Address *
City *
State *
Zip Code *
Parents of students that are minors should complete the section below:
Father’s Name
Father’s Contact Phone Number
Father’s Email Address
Father’s Mailing Address (Leave blank if same as student)
Mother’s Name
Mother’s Contact Phone Number
Mother’s Email Address
Mother’s Mailing Address (Leave blank if same as student)
How Did You Hear About Us? *Internet SearchPerformance AttendanceReferal From A Current StudentReferal From An Ex-StudentReferal From Another TeacherFacebookYoutubeLinked-InOther
Please check all that apply:
Monday - Early Afternoon
Monday - Afternoon
Monday - Evening
Tuesday - Early Afternoon
Tuesday - Afternoon
Tuesday - Evening
Wednesday - Early Afternoon
Wednesday - Afternoon
Wednesday - Evening
Thursday - Early Afternoon
Thursday - Afternoon
Thursday - Evening
Saturday - Morning
Saturday - Early Afternoon
1 + 3 = ?Please prove that you are human by solving the equation *