Name* 

Student's name (if different) 

Phone number* 

E-mail address* 

Where would you like tutoring to take place? 

Home address* 

Name of the neutral location 

State 

City 

Age of student 

Is the student enrolled in school? 

Attach a class syllabus if available. 

Name of the school that the student is attending 

Grade level of student 

Please describe the student's needs to the best of your ability 

Does the student have any disabilities? 

Please describe the student's disabilities to the best of your ability 

Would you prefer a male or female tutor? 

Which days of the week would you like the tutoring sessions to occur? 








What time of the day would you like the tutoring sessions to occur? 

Date you would like to begin tutoring sessions 

How did you hear about us? 

We require a $15.00 start-up fee to register clients for our services. Failure to pay the fee will result in the cancellation of your registration. If you would like to pay using Bitcoin or Litecoin, please contact us immediately after filling out this form. We will refund the sign up fee if a tutor is unavailable to assist you.
Initiation fee 


Initials* 

Date* 


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