Student’s Name
Age
Grade
Date of Birth
School Attending
Father’s Name
Father’s Cell Phone
Mother’s Name
Mother’s Cell Phone
Address 1
Address 2
City
State
Zip
Email Address
Emergency Contact Name
Relationship
Emergency Contact Cell
Home
Does your child have any allergies (especially food allergies), other medical conditions, or take any medications that may influence his/her ability to learn? (Please list and explain below.) (optional)
Is your child right-handed? YesNo
What are the strengths of your child? (In all areas, not just academics)
What are the developing areas of your child? (In all areas, not just academics)
In regards to academics, what are your biggest concerns for your child?
What do you hope your child will gain as a result of these tutoring sessions?
Is there anything else regarding your child, their academic needs, or their behavior that I, as a tutor, should know?
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