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Student's Full Name

Sex:(Required)

Male

Female

Date Of Birth

Age

School(Required)

Grade(Required)

Parent's or Guardian's Full Name(Required)

Mobile Phone(Required)

Email Address(Required)

Parent's or Guardian's Full Name(Required)

Mobile Phone(Required)

Email Address(Required)

Emergency Name(s) and Number(s)(Required)

Home Address(Required)

Do you have any pets at home?(Required)

Yes

If so, which ones?

What services do you need?(Required)

Preferred Days & Times of Services?(Required)

What are your goals out of services with us?(Required)

what are your concerns about your child's education?(Required)

Please list any additional notes(Required)

Photo Release Permission Slip

As the parent or guardian, I hereby consent to the use of photographs and/or videotapes taken during sessions. This material may be used for publicity, promotional, and/or educational purposes (including publications, presentations, or digital media). I provide this consent with full knowledge and understanding.

Consent(Required)

Yes, I give consent for Isabella Mordechaieb to photograph my child.

No, I do not authorize Isabella Mordechaieb to photograph my child.

Parent's Full Name

Student's Full Name

Signature

Date

PLEASE CHECK OFF EACH BOX TO ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO THE FOLLOWING STATEMENTS. THANK YOU!

I agree to pay for tutoring immediately upon the completion of each tutoring session or abide by the payment plan if one was agreed upon by both the tutoring company and parent.

Payment may be accepted in the form of cash, check, Zelle, or Venmo.

We understand that there might be instances where classes will have to be canceled but please try to cancel at least 6 hours before the tutoring session; if not, a charge of the session will be made.

There are no refunds for the lessons, instead the money will go towards the next session.

Monthly progress reports will be given to the parent of the student to inform them on the progress that is being made and what needs to be worked on.

Parent/Guardian Signature

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Today's Date

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Contact Information

Registration Form

Photo Release Permission Slip

Contact Information

Tutoring Services