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mathytutor@yahoo.com
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New/Prospective Clients - Information Form
This information is very important for my records.  Rest assured, however, that I will never share your information with anyone other than you, the student, the student's family, and possibly the student's teacher.

Note that only questions with a * are required.  However, I will ask for all of the following information eventually, so it is best that you answer as many questions as you are able.

If you are a new client, I will contact you as soon as I receive the information in this form.

Please be sure to look at my availability & daily schedule and policies.  You may also find the following pages to be of interest: about me, students page, rate comparisons (and why choose my services), subjects I tutor, credentials, flier.
E-mail Address: *
Other Family Email Addresses (Include Whom):
Mother - First Name: *
Mother - Last Name:
Does the mother live with the student?
Father - First Name: *
Father - Last Name:
Does the father live with the student?
Student - First Name: *
Student - Last Name:
Student - Grade Level:
Student - Math Level:
Student - School Name:
Student - Textbook Title:
Student - Textbook Editor OR Author Name:
Teacher - Name:
Teacher - Email Address:
Teacher - Phone Number (Area Code First):
Days/Times Available for Tutoring (M-F only):
Desired Number of Tutoring Hours per Week:
Should these tutoring hours be consecutive or on separate days?
Home Phone (Area Code First): *
This is a Home Phone Number for:
Mother - Work Phone (Area Code First):
Mother - Mobile Phone (Area Code First):
Father - Work Phone (Area Code First):
Father - Mobile Phone (Area Code First):
Student - Mobile Phone (Area Code First):
Home Address - Street # and Name / Apt #:
Home Address - City Name: *
Fax (Area Code First):
Website Address:
Other Information:
How did you hear about my services? *
Questions/Comments:
I have read & I agree to sign your policies: *Yes
No
I have questions for you first
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