Parent/Guardian * First Name Last Name Phone * Country (###) ### #### Email * Preferred method of contact * Phone Email Text Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Student Information Student Name * First Name Last Name Date or Birth * MM DD YYYY Grade Level * 3 4 5 6 7 8 9 10 11 12 College/University School Name * Academic Needs & Goals What subject(s) does the student need help with? * Reading & Phonics Writing & Grammar Math Science Social Studies Geography English Language Arts Earth, Life & Physical Sciences U.S. History & Civics History & Government Foreign Languages What are the student’s academic strengths? * What are the student’s academic challenges? * Are there any diagnosed learning differences or special education needs? * None SLD: Specific Learning Disability LD: Learning Disability LBLD: Language-Based Learning Disability SpLD: Specific Learning Difficulty MLD: Moderate Learning Difficulties SLD: Severe Learning Difficulties PMLD: Profound and Multiple Learning Difficulties. If yes, please describe: What goals would you like to achieve through tutoring? * Scheduling & Availability Preferred Days for Tutoring * Monday Tuesday Wednesday Thursday Friday Saturday Preferred Time(s): * Morning (9-12) Afternoon (1-4) Evening (5-8) Preferred Tutoring Format: * Virtual In-person Hybrid Start Date Requested: * MM DD YYYY Session Frequency: * Weekly Bi-weekly As needed Additional Information Is there anything else we should know about the student or your expectations? * Authorization & Agreement * By checking the box, I certify that the information provided is accurate. I understand that Qualteach Tutoring Agency will use this information to match my student with a suitable tutor and communicate with me regarding services. Thank you!
