Smart Kidz Tutoring Program Registration

Smart Kidz Tutoring 2012 - 2013 Application Form

Please complete the below form to register for the Smart Kidz Tutoring program. A separate form must be submitted if you are registering more than one child.

Child's Name*
FirstLast
Date of Birth*
Age*
Grade (as of Sept. 2012)*
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Parents' Name*
Home Phone*
Work Phone (Mother)
Work Phone (Father)
Cell Phone
Email*
School attending in September 2012?*
Emergency Contact*
FirstLast
Relation to Child*
Emergency Contact Number*

Please complete:
Tell us a little bit about your child's attitude toward school and learning.*
Tell us about your child's learning style.*
What goals/areas would you like to see worked on?*
How much time does your child spend on homework each night?*
What academic difficulties does your child experience at school?*
What are some of your child's strengths?*
Please list the main objectives you would like to see addressed in our program.*
Does your child have a learning disability/AD(H)D? If yes, please specify.*
Please describe any resource assistance or enrichment services your child receives at school (specify when and what is covered). Does your child have an I.E.P.? *
What accomodtions, if any, have successfully helped your child in the classroom?*
Has your child attended any other tutoring programs before? If yes, please specify.*
Additional comments that will assist us in educating your child.*

Smart Kidz Tutoring Program Registration

Smart Kidz Tutoring 2012 - 2013 Application Form

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