In-Home Tutoring Application - Support for Students Growth Center

Please answer the following questions to the best of your ability.

We only employ highly experienced ESE Certified Professional Educators or Licensed Therapists to provide the very best service possible.

Student Name

Last Name *

First Name *

Middle Initial

Birthdate *

Age *

Grade *

Gender *

Male

Female

Name of Parent or Guardian

Last Name *

First Name *

Number of Siblings *

Ages of Sibllings

Current Address *

Current Address

Street Address

Apt. Number

City

State/Province

Zip/Postal

Home Phone *

Parent Cell Phone *

Parent Email *

Referred by *

Does the student participate in the Gardiner Scholarship (PLSA)? *

Yes

No

In what subject(s) does your child need tutoring? *

What type of tutoring are you looking for? (Select all that apply) *

How often would you like your child tutored? (each session is 60 minutes) *

Once per week

Twice per week

Three or more times per week

As needed

Preferred tutoring times *

Weedays

Weekends

Both

Preferred tutoring location *

Home

Public Library

Other

Preferred tutoring location address *

Medical/psychological diagnosis’s that have been given for student? (if any) *

Has student repeated any grades? *

Yes

No

If yes, what grade(s)?

Does the student have an IEP or 504 Plan? *

Yes

No

If yes, for what?

Does the student have any health impairments? *

Yes

No

If yes, please explain?

What are your child’s strengths? *

What are your child’s limitations? *

What concerns have brought you to seek our services at this time? *

School Information

Where does your child attend school? *

What type of class setting? How are the child’s grades? *

Social and Behavioral Information

What does your child like to do? Do they excel in any sport, academic, or activity? *

What specific situations or events trigger frustration or anxiety in your child? *

Please explain how your child relates to other children in school or in other settings *

What changes in the behavior of your child have you seen lately? *

Does your child have sensory issues? *

Yes

No

Do they have a “special interest” ? *

Yes

No

Do they display rigid behaviors? *

Yes

No

Please explain, if yes to any of the above 3 items

Tutoring Packages

Select Your Package *

5 Pack $500

10 Pack $975

20 Pack $1850

Limitations of Liability and Signature

I understand that the Support for Students Growth Center (S.S.G.C.) strives to help as many clients as they can. However, I understand that not all applicants are accepted for services. I understand that the S.S.G.C will use the application information to assess my child’s needs for the purposes of evaluating their abilities and needs and determining placement and service options. Recommendation and approval of my child for services provided by the S.S.G.C is at the discretion of the S.S.G.C administrative team.

Our tutors are not “baby sitters” and therefore, a trusted person 18 years of age or older must be in the home or other setting, while tutoring occurs. Tutoring may never occur in a bedroom or in a room with a closed door.

Cancellation Policy: You may cancel your tutoring/counseling session with no penalty up to 24 hours before the scheduled session. If, however, you cancel within 24 hours of the session, payment is due in full (except for an occasional sudden incident or illness). Please be sure to contact your tutor once you know you need to cancel or re-schedule.

Refund Policy: All payments, including initial assessments and deposits, are non-refundable. Refunds will not be given for withdrawals or dismissals after services have begun. If a child engages in conduct which is harmful, dangerous, or extremely disruptive to the overall conduct of the program or the personnel of S.S.G.C., we reserve the right to dismiss the child, and a prorated refund may be offered.

I agree to the cost and payment terms agreed upon and understand that these services will likely not be paid for or reimbursed by my insurance company. I agree to hold harmless the S.S.G.C as well as its employees or representatives from any damages or losses of any kind including direct, indirect, incidental, consequential or punitive damages arising out of the applicant’s and/or child’s participation in their programs. I understand that the S.S.G.C makes no warranty or guarantee of any kind whatsoever regarding results or outcomes, whether direct or indirect, from the services it provides. In submitting this application, I certify that the information provided herein, including all enclosed documents, is complete and accurate to the best of my knowledge. I understand that failing to provide complete and accurate information in or with this application will void any potential refunds.

I have read the above information - Enter Your Initials below *

I am the parent or legal guardian (an individual if over 18) of the child/participant named in this application, and I agree to the terms and conditions outlined above.

Sign the application by entering your full name in the field below *

Please select your form of payment below
- If paying by credit card, payment must be made with application submittal. After clicking submit below, you will be taken to the payment page.
- If you have chosen to pay by Cash or Check you will need to visit our Boca Raton office to make payment, prior to your first session.
- If you have chosen Step Up For Students Scholarship, please contact the office (561-990-7305) with your information after submitting the application.

Select Payment Type *

Credit Card (We use PayPal, no account is needed)

Check or Cash at Boca Office (Receive 5% discount)

Step Up For Students Scholarship (Call the office with your information)

Coupon Code

ONLINE TUTORING APPLICATION

Student Name

Name of Parent or Guardian

School Information

Social and Behavioral Information

Tutoring Packages

Limitations of Liability and Signature

Contact

Our Address

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