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Registration Form for C2 Tutoring Service
Student Information:                         Student  email
First name         Last name           M.I.
Gender M    F                  Date of birth (mm/dd/yy)
Address 
City       State            Zip Code
Phone                  Grade Level
 
Subject for which
you will be tutored		 Name of Instructor Instructor's Years
of Experience
     

Please describe briefly how you learn best and what you see as your source of difficulty in the subjects listed above. Also, include how you expect your performance to be impacted as a result of using this service. What do you see as your role in this process?

 
.Please check the items you will submit with your registration form:
Course syllabus

Course textbook information (Please specify title, author, publisher, copyright & edition below)
Copies of any type of interim reports, progress reports or grades
Copies of important assignments, quizzes and tests
 
Parent/Guardian Information:                 Parent  email
Last name      First name     Relationship
Address (if different)
City       State            Zip Code
Home Phone           Work Phone       (include area code)
 
In the space below, please briefly describe your child's source of difficulty in the course(s) for which your child will be tutored. What do you see as your role in this process?
   
How often will you be using the service?
Once a week
Twice a week
Three times a week 		Preferred method of payment:
Cash
Check
Money order
   
How did you learn about the service?
Friend
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School

 

Client of the service
Other

Any comments or questions?

The hourly rate is $75.00 and the rate for 40 minute sessions is $60.00. Payment is due upon the completion of each session. Based on the time slot requested by each client, sessions are over 40 minutes or 60 minutes after their scheduled time, not student arrival time. Notice of cancellation must be given twenty four hours in advance of the appointment time or a $25.00 late fee will be applied to your account. The fee for returned checks is $35.00.

Signature (can be signed when service is initiated)_____________________________

Date of signature____________________________

PLEASE PRINT OUT THIS FORM for your records before submitting. Alternatively, you may print out the form, fill it out and then mail or bring it to me.

Thank You!

Note: If the required fields (names, email addresses and phone numbers) are not filled in, an error message will appear. You can then press the Back button to return to this form and complete those fields.