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ENROLLMENT FORM 2011-2012
New Client:_____ Date:_____________
Returning client______
STUDENT’S NAME__________________________________ B.D.______________AGE_________
PARENT’S NAME______________________________________________SCHOOL_____________
ADDRESS___________________________________________GRADE________TEACHER_________
CITY_______________________________STATE_________ ZIP____________________
PHONE(S)_____________________WORK__________________________CELL#_________
Home (PLEASE NOTE WHICH PARENT)
EMAIL:_____________________________________________________________(optional)
Primary purpose for requesting our services:_________________________________________________
___________________________________________________________________
Please indicate the math level ie. geometry, AP calculus, trig. etc., as well as AP or honors subjects
Please prioritize the subjects/areas you wish to have emphasized in the tutoring:
1:___________________________________________2:____________________________
Please summarize relevant parts of your child’s school history (retention, moves, combination classes, personality conflicts, illness, etc.) which may be relevant:
___________________________________________________________________
Is tutoring viewed as _____general support ____remedial ____enrichment
Is any language other than English spoken in the home/school?_______________________
Has your child ever been tested for learning disabilities either by the schools or privately? If so, please share the results with us. Yes__________No________
Does your child have an IEP? Yes______No________ If YES, please provide a copy.
Does your child have a 504 Plan Yes_____No________If YES, please provide a copy.
Is your child currently being seen by any other agency or personnel to support his/her
education(e.g. speech services, or other tutors)? Yes____________No____________
Please list:_________________________________________________________________
Has your child been diagnosed with any syndrome which would require a learning specialist? Yes__No__
TUTORING CHOICES: Please circle your choice
1 hour weekly 45 minutes ONCE weekly
2 hours weekly 45 minutes TWICE weekly
3 hours weekly 45 minutes THREE times weekly
Hourly Rates:
General tutoring: $48.50 per hour
Learning Specialist: $56 per hour
Physics, pre-calculus, calculus, trigonometry, $57 per hour
chemistry, and ALL AP OR Honors subjects
Shared sessions (contact the office)
RATES and PAYMENTS
Please select a plan from the above tutoring choices that best suits your child’s needs. Statements are mailed on the 15th of the month and are due by the FIRST of the month. Payments are due in advance of each month’s tutoring. Late or partial payments will result in an $18 late charge. Returned checks will result in a $25 fee. Clients who are 2 months behind in payments are automatically dropped from the program.
New clients are asked to provide the center with sufficient material and information to set up an educational program. A brief educational screening may be completed, if needed, for a $90 fee. This can help determine the direction of the tutoring. This is not mandatory. In certain cases, we ask that new clients have a conference with the child’s tutor at Pacific Learning Center in advance of the first tutorial session. This is at the discretion of the teacher; however, if a child has a history of learning difficulties or attention difficulties, it is required. This meeting is waived most often for a returning client or a situation in which the direction for the tutoring program is very clear.
Conferences may be scheduled at any time. Please call the office to make arrangements for a parent/teacher meeting. Our teachers are often able to attend school conferences if needed. The charge for teacher conferences (by phone or in person) will be at the students’ hourly rate IF longer than 10 minutes. Consultations may also be scheduled with the director (Carol Taylor) to discuss special situations. The charge for these consults will be at the rate of $56 per hour. Written reports or year end reports are available upon request at the rate of $20 per report. Most
parents find these reports to be very valuable.
Please describe any health conditions (allergies, diabetes, etc.) of which we should be aware:_______________________________________________________________
Please list any medications prescribed:______________________________________
What is your child’s attitude about attending tutorial sessions?
____Positive _____Fair _____Reserved _____Hesitant
Emergency Information
Please list a friend, relative or neighbor we can contact in case of emergency:
Name_____________________________Relationship____________ Phone#_________
In the case of younger children, please list the individual(s) to whom we are authorized to release your child:
Name:_______________________________________ Phone#_____________________
THE FOLLOWING INFORMATION IS HELPFUL TO US IN SETTING UP A PROGRAM FOR YOUR CHILD. PLEASE MAKE A SPECIAL EFFORT TO PROVIDE US WITH AS MANY OF THESE ITEMS PRIOR TO YOUR CHILD’S FIRST SESSION.
*Copy of recent report cards *Work samples for subject area of concern
*Copies of progress reports *Names of reading/math series or approaches used
*Copies of standardized tests *Note from teacher regarding priorities of tutoring
SPECIAL NOTE*** I f you would like the tutor to communicate with your child’s teacher, please sign and date an authorization on the bottom of this form.
SCHEDULING PREFERENCES
Teacher preference(if known)___________________________ Start date:________
Days of the week preferred: M T W TH F SAT*
if available
Days NOT possible: M T W TH F
Number of sessions each week_____________ Length of sessions_______________
Time of day preferred:
Mornings (for kindergartners,etc.)__________________________________
Afternoons/Evenings:
1:30 1:45 2:00 2:15 2:30 2:45 3:00 3:15 3:30 3:45 4:00
4:15 4:30 4:45 5:00 5:15 5:30 5:45 6:00 6:15 6:30 6:45
7:00 7:15 7:30 7:45 8:00
**********CANCELLATION POLICY********
Once a schedule is set up, the time(s) you have chosen are reserved for your child. If a STUDENT needs to cancel a session, please call the office directly (NOT the tutor). Regardless of the reason for the cancel (illness, conflict, etc.) it will be billed at your hourly rate and is not refundable nor can it be made up without an additional fee of $48.50/56/57 and only if the tutor’s schedule allows. If a TUTOR needs to cancel a session a substitute will be provided when possible to ensure continuity of teaching. If a substitute is not requested or available, a refund or credit will be issued.
If you wish to discontinue tutoring services, we require 30 DAYS notice directly to the OFFICE or in writing.
HOLIDAYS
Pacific Learning Center honors national holidays. We are NOT closed on teacher in-service days or minimum days. Since we deal with many different school districts our holiday closures may differ from your school’s closure . Our holiday schedule will be included with your schedule confirmation and a copy is always posted in the waiting room. Feel free to request another copy at any time so we may avoid any misunderstandings about our closure dates. |
