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Enrollment Application

Today's Date *

Today's Date

Name *

First

Last

Birthdate *

Birthdate

Parent/Guardian Names *

First

Last

Street Address

City

State & Zipcode

Parent/Guardian Email

Parent/Guardian Cell Phone

Primary Number #

Other

School student is attending now (if applicable)

Grade Level

In what areas of academics are you seeking assistance?

(If school course) Textbook Tile

ISBN#

If the student has any learning difference about which we should be aware, please explain

Please check the boxes of the days and times when this student can attend sessions: (note * only offered in summer)

How did you hear about Tailored Tutoring LLC or who referred you?

Initial fees paid upon enrollment/Date/Check#/Total Amount Paid

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