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Note: If you have multiple children, please complete a form for each child.

Learning Pod

Learning Pod Intake Form

Student Name

First Name

Last Name

Age of student/ and grade

Guardian Name

First Name

Last Name

Email

Phone

(###)

###

####

Learning Pod Options:

AVIATORS T/W/TH

JETSETTERS T/TH

GLIDERS W

What are some learning challenges and strengths that your child has?

What is your child's personality and interests?

Do you have multiple children wanting to enroll?

Yes

Student's Name

If checked yes above fill out:

First Name

Last Name

How did you hear about us?

Leave a message or Questions?

I am interested in

INTAKE FORMS

Academic Tutoring

Tutoring Intake form

Student's Name

First Name

Last Name

Age

Name of School or homeschool

Grade

If homeschooled, what grade level do you think they are performing at?

Guardian's Name

First Name

Last Name

Email

Phone

(###)

###

####

What services are you interested in?

Academic tutoring

buddy tutoring

Online reading intervention

In person/ online tutoring

In your opinion what is your child struggling with?

Is your child's learning affecting their confidence? If so, how?

What does your child's teacher say about their learning?

What are your expectations for tutoring?

What are some learning challenges/strengths your child has?

Does your child have a diagnosis that affects their learning?

What is your child's personality and interests?

Available date to begin

MM

DD

YYYY

Days and times that work best:

How many times a week are you interested in? Please note that your child may need 2 or more times a week depending on assessment results.

How did you hear of us?

Message or Questions

Online Reading Intervention

Online Tutoring Intake form

Student's Name

First Name

Last Name

Age

Name of School or homeschool

Grade

If homeschooled, what grade level do you think they are performing at?

Guardian's Name

First Name

Last Name

Email

Phone

(###)

###

####

What services are you interested in?

Academic tutoring

buddy tutoring

Online reading intervention

In person/ online tutoring

In your opinion what is your child struggling with?

Is your child's learning affecting their confidence? If so, how?

What does your child's teacher say about their learning?

What are your expectations for tutoring?

What are some learning challenges/strengths your child has?

Does your child have a diagnosis that affects their learning?

What is your child's personality and interests?

Available date to begin

MM

DD

YYYY

Days and times that work best:

How many times a week are you interested in? Please note that your child may need 2 or more times a week depending on assessment results.

How did you hear of us?

Message or Questions

Learning Pod

INTAKE FORMS

Academic Tutoring

Online Reading Intervention

(208) 431-0894