Houston Tutorial Association » Student Enrollment Form

Student Enrollment Form

Student First Name:

Student Last Name:

School:

Grade:

Date of Birth:

Areas of Need/Subject:
Check all that Apply

Study Skills
General Studies
Reading Comprehension
Writing
English
History
General Math
Algebra
Calculus
Geometry
Science
Biology
Geology
Chemistry
Physics
Physical Science
Spanish
French
Latin
SAT Verbal
SAT Math
SAT Writing
Other

Parent Name(s):

Email Address:

Address:

City:

State:

Zip Code:

Phone (home):

Responsible Party for Payment:

Known Learning Disabilities:

Personality of Student:

Referred By:

Availability (days):
Check all that Apply

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Availability (times):
Check all that Apply

Daytime
Early Afternoon
Evenings
Weekends - Anytime

Comments:

Terms and Conditions:

By submitting this Student Enrollment Form, the parent, client or guardian agrees to the financial obligations and policies set forth in the following paragraphs.

A one time initial processing fee of $50 is due prior to receiving any tutorial placements. Tutoring services will be billed at the time of service, unless arranged otherwise. Payment is due within 5 days of receipt of the Statement of Services. The hourly rate is subject to change based upon the Association�s annual review of its rates.

Cancellation Policy: Except in emergency situations, cancellations not made at least 4 hours in advance of the session result in full charge for that session.

Do you agree?:

agree