Contact Submission

Fax it to 717.664.1535

Phone: 717.664.1016

When we speak with you we will need information about you and your child as shown below.

Parent/Guardian Last Name:__________________________________

Parent/Guardian First Name:__________________________________

Age of student(s):_________________ Grade Level:_______________

Name of school:____________________________________________

If home-schooled, name of curriculum:__________________________

Extra-curricular activities your child(ren) is involved in after school, i.e. sports, dance,
music lessons, etc.________________________________________

Has your child(ren) ever had a tutor in your home?_____________________

List any special needs or learning disabilities:_________________________

Most convenient time of day for tutoring:______________________________

A parent or guardian over the age of 21 must be in the home for the entire tutoring session

How do we get in touch with you?

Phone(___)__________________________

Email:_______________________________

Fax:_________________________________

Best time to call?_______________________

Does your child(ren) know you are considering hiring a tutor?____________