Child's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Parent's Phone *

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Individual or Group Sessions

Individual Sessions (50 Minutes)

Partner Sessions (2 learners) (60 minutes)

Group Sessions (3 learners) (60 minutes)

Individual Sessions (75 minutes)

Partner Sessions (2 learners) (90 minutes)

Group Sessions (3 learners) (90 minutes)

What days best fit your schedule? *

Choose all that apply

Monday

Tuesday

Wednesday

Friday

What times best fit your schedule? *

Open sessions are between 8:30 am-1 pm. Please list three options that best fit your schedule. If you have opted for a 90 minutes session , please choose the two back-to-back time slots that best work for you.

8:45 am-9:45 am

9:45 am-10:45 am

10:45 am-11:45 am

11:45 am-12:45 pm

12:45 pm-1:45 pm

How many sessions would you like to request? *

One session per week for 4, 8, or 12 weeks

4

8

12

What subject areas does child need support in? *

Math

Language Arts (reading and writing)

Other