Mullins Tutoring, Inc.

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Mullins Tutoring, Inc.

TUTORING REGISTRATION FORM
 
Today’s date:_____________________________________________________________________________________________________
 
STUDENT INFORMATION
Student:                Last name:___________________________________ First:_________________________________________________
Parent/Guardian:   Last name: ___________________________________First:_________________________________________________
Parent/Guardian:   Last name: ___________________________________First:_________________________________________________
Student date of birth: ________________________________________________________________________________________________
 
Street address: _____________________________________________City:_________________________ ZIP Code:__________________
Home phone: _________________________ Cell phone: _________________________________ Work Phone________________________
Parent email: ______________________________________________ Student email:_____________________________________________

 

Referred by (please check one box): []School  []Internet Search [] Family/Friend []Ad  []Other

Tutoring location preference: ______________________________ Tutoring schedule preference: ____________________________________

SCHOOL/COURSE INFORMATION
School: _________________________________________________ Grade/Level: ______________________________________________

Course(s):  _______________________________________________________________________________________________________


Difficult topics:______________________________________________________________________________________________________

 

Strong topics: ______________________________________________________________________________________________________

Tutoring goals: ______________________________________________________________________________________________________


Other academic issues, if any, that tutor should know about:______________________________________________________________________________________________________________

PAYMENT INFORMATION
Person responsible for payments:__________________________________ Relationship to student:__________________________________
Address, if different from above: ________________________________________________________________________________________

Home phone: ____________________________________________Cell phone: __________________________________________________
 
Check (due in advance) or Paypal for credit card payments: 

Invoice will be  Emailed monthly to: ______________________________________________________________________
The above information is true to the best of my knowledge. I received and read the Mullins Tutoring, Inc. – Tutoring Policies. I agree to all terms and conditions outlined in Mullins Tutoring, Inc. - Tutoring Policies. Payment by check or cash is due by the fifth of the month.

Student signature_____________________________________________________________________ Date ___________________________

Patient/Guardian signature______________________________________________________________ Date ___________________________