First Name *

Last Name *

Phone Number *

Email *

Email (Confirmation) *

Country *
- Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentine Republic Armenia Aruba Australia Austria Azerbaijan Azores Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Do Not Use Do Not Use Do Not Use Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S Georgia Sandwich Islands Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent The Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan, Rc Tajikistan Tanzania Thailand The Bahamas The Congo Togolese Republic Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Western Sahara Western Samoa Yemen Zambia Zimbabwe

Address 1 *

Address 2

City *

State *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming - Select Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Zip Code *

Time Zone *
- Select Option Eastern Daylight Time (EDT) Central Daylight Time (CDT) Mountain Daylight Time (MDT) Mountain Standard Time (MST) Pacific Daylight Time (PDT) Alaska Daylight Time (AKDT) Hawaii-Aleutian Standard Time (HDT) Hawaii Standard Time (HST)

Are you utilizing a scholarship, grant, or education savings account for our tutoring services? If yes, please select from below: *
- Select Option Arkansas Learns Children’s Scholarship Fund NH Indiana Learns North Carolina’s Education Student Accounts (ESA+) program Odyssey Idaho: Empowering Parents Odyssey Missouri: Close the Gap Grant Virginia K-12 Learning Acceleration Grant Not at this time AZ Learns Scholarship: Empowerment Scholarship Account Program Not listed Please specify a value for Are you utilizing a scholarship, grant, or education savings account for our tutoring services? If yes, please select from below:

Are you a Grand Valley State University faculty/staff member? *
Yes
No

I give permission for K-12 Connect staff to schedule on behalf of the student(s) listed in this form and to have access to their educational record.

First Name *

Last Name *

What is the primary language of this student? *
- Select Option English Spanish Arabic French German Chinese Not listed Please specify a value for What is the primary language of this student?

Is this student Hispanic or Latino?
Yes
No

Select one or more of the following races:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Not listed Please specify a value for Select one or more of the following races:

Pronouns (select all that apply)
She/Her/Hers
He/Him/His
They/Them/Theirs
Not listed Please specify a value for Pronouns (select all that apply)

Sex *
Male
Female
Prefer not to disclose
Not listed Please specify a value for Sex

Birth Date *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Grade (2023/2024 school year) *
- Select Option K 1 2 3 4 5 6 7 8 9 10 11 12 Not listed Please specify a value for Grade (2023/2024 school year)

School *

School District *

Program Options *
- Select Option Reading Math (1st grade - Algebra 1) High School Academic Mentoring

Is there anything you would like us to know about your student's reading experience?

Is there anything you would like us to know about your student's math experience?

Please select the subjects your student most needs support in (select all that apply). *
Algebra
Biology
Chemistry
History
Math
Reading
Science
Writing

Please select the subjects your student most needs support in (select all that apply). *
Goal Setting
Learning Styles
Organization
Study Skills
Test Prep
Not listed Please specify a value for Please select the subjects your student most needs support in (select all that apply).

Is there anything you would like us to know about your student's academic experience?

What days are you and your student available for your tutoring sessions? *
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please select all times you and your student are available on Mondays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Tuesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Wednesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Thursdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Fridays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Saturdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Sundays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select any of the below options, if they apply to your student.
Student receives special education services
Student qualifies for free/reduced price meals at school
Student is an English Learner
Student is eligible for Migrant Education Program

If your student receives special education services and you have documentation of their plan, please upload this here so that we can best accommodate and serve your student.
Please upload a file with the extension .doc, .pdf, .rtf, .pages, .docx, .odt, .pub, .bmp, .gif, .jpeg, .jpg, .png, .tiff, .webp, or .txt with a maximum size of 5 MB (5120 KB)

Is there anything we should know about this student? (i.e. special interests, hobbies, needs, etc.)

First Name *

Last Name *

What is the primary language of this student? *
- Select Option English Spanish Arabic French German Chinese Not listed Please specify a value for What is the primary language of this student?

Is this student Hispanic or Latino?
Yes
No

Select one or more of the following races:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Not listed Please specify a value for Select one or more of the following races:

Pronouns (select all that apply)
She/Her/Hers
He/Him/His
They/Them/Theirs
Not listed Please specify a value for Pronouns (select all that apply)

Sex *
Male
Female
Prefer not to disclose
Not listed Please specify a value for Sex

Birth Date *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Grade (2023/2024 school year) *
- Select Option K 1 2 3 4 5 6 7 8 9 10 11 12 Not listed Please specify a value for Grade (2023/2024 school year)

School *

School District *

Program Options *
- Select Option Reading Math (1st grade - Algebra 1) High School Academic Mentoring

Is there anything you would like us to know about your student's reading experience?

Is there anything you would like us to know about your student's math experience?

Please select the subjects your student most needs support in (select all that apply). *
Algebra
Biology
Chemistry
History
Math
Reading
Science
Writing

Please select the subjects your student most needs support in (select all that apply). *
Goal Setting
Learning Styles
Organization
Study Skills
Test Prep
Not listed Please specify a value for Please select the subjects your student most needs support in (select all that apply).

Is there anything you would like us to know about your student's academic experience?

What days are you and your student available for your tutoring sessions? *
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please select all times you and your student are available on Mondays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Tuesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Wednesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Thursdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Fridays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Saturdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Sundays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select any of the below options, if they apply to your student.
Student receives special education services
Student qualifies for free/reduced price meals at school
Student is an English Learner
Student is eligible for Migrant Education Program

If your student receives special education services and you have documentation of their plan, please upload this here so that we can best accommodate and serve your student.
Please upload a file with the extension .doc, .pdf, .rtf, .pages, .docx, .odt, .pub, .bmp, .gif, .jpeg, .jpg, .png, .tiff, .webp, or .txt with a maximum size of 5 MB (5120 KB)

Is there anything we should know about this student? (i.e. special interests, hobbies, needs, etc.)

First Name *

Last Name *

What is the primary language of this student? *
- Select Option English Spanish Arabic French German Chinese Not listed Please specify a value for What is the primary language of this student?

Is this student Hispanic or Latino?
Yes
No

Select one or more of the following races:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Not listed Please specify a value for Select one or more of the following races:

Pronouns (select all that apply)
She/Her/Hers
He/Him/His
They/Them/Theirs
Not listed Please specify a value for Pronouns (select all that apply)

Sex *
Male
Female
Prefer not to disclose
Not listed Please specify a value for Sex

Birth Date *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Grade (2023/2024 school year) *
- Select Option K 1 2 3 4 5 6 7 8 9 10 11 12 Not listed Please specify a value for Grade (2023/2024 school year)

School *

School District *

Program Options *
- Select Option Reading Math (1st grade - Algebra 1) High School Academic Mentoring

Is there anything you would like us to know about your student's reading experience?

Is there anything you would like us to know about your student's math experience?

Please select the subjects your student most needs support in (select all that apply). *
Algebra
Biology
Chemistry
History
Math
Reading
Science
Writing

Please select the subjects your student most needs support in (select all that apply). *
Goal Setting
Learning Styles
Organization
Study Skills
Test Prep
Not listed Please specify a value for Please select the subjects your student most needs support in (select all that apply).

Is there anything you would like us to know about your student's academic experience?

What days are you and your student available for your tutoring sessions? *
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please select all times you and your student are available on Mondays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Tuesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Wednesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Thursdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Fridays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Saturdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Sundays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select any of the below options, if they apply to your student.
Student receives special education services
Student qualifies for free/reduced price meals at school
Student is an English Learner
Student is eligible for Migrant Education Program

If your student receives special education services and you have documentation of their plan, please upload this here so that we can best accommodate and serve your student.
Please upload a file with the extension .doc, .pdf, .rtf, .pages, .docx, .odt, .pub, .bmp, .gif, .jpeg, .jpg, .png, .tiff, .webp, or .txt with a maximum size of 5 MB (5120 KB)

Is there anything we should know about this student? (i.e. special interests, hobbies, needs, etc.)

First Name *

Last Name *

What is the primary language of this student? *
- Select Option English Spanish Arabic French German Chinese Not listed Please specify a value for What is the primary language of this student?

Is this student Hispanic or Latino?
Yes
No

Select one or more of the following races:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Not listed Please specify a value for Select one or more of the following races:

Pronouns (select all that apply)
She/Her/Hers
He/Him/His
They/Them/Theirs
Not listed Please specify a value for Pronouns (select all that apply)

Sex *
Male
Female
Prefer not to disclose
Not listed Please specify a value for Sex

Birth Date *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Grade (2023/2024 school year) *
- Select Option K 1 2 3 4 5 6 7 8 9 10 11 12 Not listed Please specify a value for Grade (2023/2024 school year)

School *

School District *

Program Options *
- Select Option Reading Math (1st grade - Algebra 1) High School Academic Mentoring

Is there anything you would like us to know about your student's reading experience?

Is there anything you would like us to know about your student's math experience?

Please select the subjects your student most needs support in (select all that apply). *
Algebra
Biology
Chemistry
History
Math
Reading
Science
Writing

Please select the subjects your student most needs support in (select all that apply). *
Goal Setting
Learning Styles
Organization
Study Skills
Test Prep
Not listed Please specify a value for Please select the subjects your student most needs support in (select all that apply).

Is there anything you would like us to know about your student's academic experience?

What days are you and your student available for your tutoring sessions? *
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please select all times you and your student are available on Mondays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Tuesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Wednesdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Thursdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Fridays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Saturdays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select all times you and your student are available on Sundays. *
8:00 a.m. - 10:00 a.m.
9:00 a.m. - 11:00 a.m.
10:00 a.m. - 12:00 p.m.
11:00 a.m. - 1:00 p.m.
12:00 p.m. - 2:00 p.m.
1:00 p.m. - 3:00 p.m.
2:00 p.m. - 4:00 p.m.
3:00 p.m. - 5:00 p.m.
4:00 p.m. - 6:00 p.m.
5:00 p.m. - 7:00 p.m.
6:00 p.m. - 8:00 p.m.
7:00 p.m. - 9:00 p.m.

Please select any of the below options, if they apply to your student.
Student receives special education services
Student qualifies for free/reduced price meals at school
Student is an English Learner
Student is eligible for Migrant Education Program

If your student receives special education services and you have documentation of their plan, please upload this here so that we can best accommodate and serve your student.
Please upload a file with the extension .doc, .pdf, .rtf, .pages, .docx, .odt, .pub, .bmp, .gif, .jpeg, .jpg, .png, .tiff, .webp, or .txt with a maximum size of 5 MB (5120 KB)

Is there anything we should know about this student? (i.e. special interests, hobbies, needs, etc.)

How did you hear about us? *
Email
Website
Word of mouth
Social media
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Not listed Please specify a value for How did you hear about us?

Who referred you to this program? Please include names as applicable. *

Is there a specific tutor you would like to request for your student(s)? *
- Select Option Yes No

Please provide the name(s) of the tutor(s) you would like your student(s) to work with. *

Is there anything else you would like to share with us?