Student Intake Form


General Information

Guardian/Parent's Name:
Student's Name:
Address:
Phone Number:
Student's Email:
Current Year in School:
Current High School:
Current Classes (please list):
Grade Point Average:
Decile:
PSAT Scores (Mat/CrRead/Writing):
SAT scores(Math/CrRead/Writing):
TOEFL scores:
ACT score:
AP Exam scores (please list):
I am registering for... (check all that apply)
College Advising
Application Edit
Essay Edit
Test Prep Class
Individual Tutoring

For College Advising:

Intended Major:
College Plans:
Preferred College Location
Urban
Suburban
Rural
College Town
Preferred College Size
Small
Medium
Large
Please list the best times to meet:

For classes:

Name of Class:
Date of Class:
Comments:

For Individual Tutoring or Private Class

How many students will be in your private session?
1
2
3
4
5
6
How many times per week?
1
2
3
How long for each session?
60 min
90 min
2 hours
Preferred location of the session?
Subject Areas for the session?
.