Student Information Form

This form collects essential information about your student and their educational needs to help us provide the best possible tutoring experience.

Student Information

Parent or Guardian Information

Parental Objectives

Student Medical Information

Emergency Contact

"*" indicates required fields

Student Information

Student 1

First Name*

Last Name*

Date of Birth*

MM slash DD slash YYYY

Grade*

School*

Address

Street Address*

Address Line 2

City*

State*

ZIP / Postal Code*

This field is hidden when viewing the form

Student-Checkboxes

Student-2

Student-3

Student-4

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Student 2

First Name*

Last Name*

Date of Birth*

MM slash DD slash YYYY

Grade*

School*

Add Another Student

Student 3

First Name*

Last Name*

Date of Birth*

MM slash DD slash YYYY

Grade*

School*

Add Another Student

Student 4

First Name*

Last Name*

Date of Birth*

MM slash DD slash YYYY

Grade*

School*

Parent Guardian Information

Parent or Guardian 1

First Name*

Last Name*

Occupation*

Employer*

Email*

Phone*

Parent or Guardian 2

First Name*

Last Name*

Occupation*

Employer*

Email*

Phone*

HasDifferentAddress

Does Parent 2 have a different address?

Street Address*

Address Line 2

City*

State*

ZIP / Postal Code*

Text Communications Consent

By checking this box, I agree to receive confirmation, scheduling, customer care, etc. text messages (SMS) from Tutoring Club. Message frequency may vary. Message and data rates may apply. You can reply STOP to opt-out at any time. For assistance, reply HELP. Check our Terms and Privacy Policy.

Parental Objectives

Student: Student 1

1. Where would you like your student to be academically?*

College Bound (2+ years above grade level)

Above average (1 year above grade level)

Average (grade level)

2. How would you best describe your student's attitude towards school?*

Very Positive

Somewhat Positive

Somewhat Negative

Very Negative

3. Which area do you feel your student needs the most improvement?*

Organizational Skills

Test Taking Skills

Study Skills

Motivation

Self-Image or Self-Esteem

4. Which of the following has been a concern for your student?*

Behavioral Problems

Lack of Attention

Missing Assignments

Shy or Withdrawn

5. How would you describe your student's self-motivation?*

High

Average

Below Average

Very Low

6. Are there any academic notes you'd like to include?

Student: Student 2

1. Where would you like your student to be academically?*

College Bound (2+ years above grade level)

Above average (1 year above grade level)

Average (grade level)

2. How would you best describe your student's attitude towards school?*

Very Positive

Somewhat Positive

Somewhat Negative

Very Negative

3. Which area do you feel your student needs the most improvement?*

Organizational Skills

Test Taking Skills

Study Skills

Motivation

Self-Image or Self-Esteem

4. Which of the following has been a concern for your student?*

Behavioral Problems

Lack of Attention

Missing Assignments

Shy or Withdrawn

5. How would you describe your student's self-motivation?*

First Choice

Second Choice

Third Choice

6. Are there any academic notes you'd like to include?

Student: Student 3

1. Where would you like your student to be academically?*

College Bound (2+ years above grade level)

Above average (1 year above grade level)

Average (grade level)

2. How would you best describe your student's attitude towards school?*

Very Positive

Somewhat Positive

Somewhat Negative

Very Negative

3. Which area do you feel your student needs the most improvement?*

Organizational Skills

Test Taking Skills

Study Skills

Motivation

Self-Image or Self-Esteem

4. Which of the following has been a concern for your student?*

Behavioral Problems

Lack of Attention

Missing Assignments

Shy or Withdrawn

5. How would you describe your student's self-motivation?*

First Choice

Second Choice

Third Choice

6. Are there any academic notes you'd like to include?

Student: Student 4

1. Where would you like your student to be academically?*

College Bound (2+ years above grade level)

Above average (1 year above grade level)

Average (grade level)

2. How would you best describe your student's attitude towards school?*

Very Positive

Somewhat Positive

Somewhat Negative

Very Negative

3. Which area do you feel your student needs the most improvement?*

Organizational Skills

Test Taking Skills

Study Skills

Motivation

Self-Image or Self-Esteem

4. Which of the following has been a concern for your student?*

Behavioral Problems

Lack of Attention

Missing Assignments

Shy or Withdrawn

5. How would you describe your student's self-motivation?*

First Choice

Second Choice

Third Choice

6. Are there any academic notes you'd like to include?

Medical Information

Student: Student 1

Any other eye or vision problems?*

Yes

If "Yes", please explain.*

Any hearing problems?*

Yes

If "Yes", please explain.*

Any speech inpairments?*

Yes

If "Yes", please explain.*

Any early childhood health issues?*

Yes

If "Yes", please explain.*

Any current health issues?*

Yes

If "Yes", please explain.*

Any current medications?*

Yes

If "Yes", please explain.*

Has your student ever had a psychological or neurological evaluation?*

Yes

If "Yes", please explain.*

Student: Student 2

Any other eye or vision problems?*

Yes

If "Yes", please explain.*

Any hearing problems?*

Yes

If "Yes", please explain.*

Any speech inpairments?*

Yes

If "Yes", please explain.*

Any early childhood health issues?*

Yes

If "Yes", please explain.*

Any current health issues?*

Yes

If "Yes", please explain.*

Any current medications?*

Yes

If "Yes", please explain.*

Has your student ever had a psychological or neurological evaluation?*

Yes

If "Yes", please explain.*

Student: Student 3

Any other eye or vision problems?*

Yes

If "Yes", please explain.*

Any hearing problems?*

Yes

If "Yes", please explain.*

Any speech inpairments?*

Yes

If "Yes", please explain.*

Any early childhood health issues?*

Yes

If "Yes", please explain.*

Any current medications?*

Yes

If "Yes", please explain.*

Has your student ever had a psychological or neurological evaluation?*

Yes

If "Yes", please explain.*

Student: Student 4

Any other eye or vision problems?*

Yes

If "Yes", please explain.*

Any hearing problems?*

Yes

If "Yes", please explain.*

Any speech inpairments?*

Yes

If "Yes", please explain.*

Any early childhood health issues?*

Yes

If "Yes", please explain.*

Any current medications?*

Yes

If "Yes", please explain.*

Has your student ever had a psychological or neurological evaluation?*

Yes

If "Yes", please explain.*

Emergency Contact

To ensure Tutoring Club is able to secure the proper medical care in case of an emergency, please complete the form below

First Name*

Last name*

Phone*

Medical Authorization Consent*

In the event of an emergency where I (or my partner) cannot be contacted, I authorize Tutoring Club to secure whatever medical care is necessary for the safety and well-being of my child. I will assume all costs incurred for emergency care.

I Agree

Full Name*

Date*

MM slash DD slash YYYY

Welcome To: Tutoring Club of Mission Viejo, CA | Find Another Location

Student Information

Student 1

Address

Student 2

Student 3

Student 4

Parent Guardian Information

Parent or Guardian 1

Parent or Guardian 2

Parental Objectives

Medical Information

Emergency Contact

Location Address:

Phone:

Email:

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