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School/District Information

District Name*

Parent/Guardian Last name *

Email*

Phone*

Student Information

Student First and Last Name*

Student's Date of Birth*

Month

Day

Year

Student's Email (if student is 18 or older)

Current Grade*

School Attending

Tutoring Needs

Subject(s) Requested:*

English/Reading/Writing

Math (Elementary)

Math (Pre-Algebra)

Algebra 1

Geometry

Algebra 2

Trigonometry

Calculus

Science (Elementary)

Geology

Chemistry

Physics

History

Other

Availability- What day(s) and time(s) do you want tutoring services each week?(Days/Times): *

If you indicated that you want tutoring in multiple subjects please specify below how often you want tutoring in each subject per week:

Preferred Start Date*

Month

Day

Year

Learning Goals & Concerns

What specific academic challenges is your child facing?

What are your goals for tutoring (short-term and long-term)?

Has your child received tutoring before? If yes, please describe.*

Does your child have an IEP, 504 Plan, or other accommodations? Yes or no? If yes, please explain*

Payment Preference

Payment Options:*

Standard Rate (Daily)- Package A

Standard Rate ( 8 sessions)- Package B

Income-Based Rate (Based on Income Eligibility)- Package C

Income Verification for Income-Based Rate:

To verify eligibility, upload at least one of the following:

Proof that your child is eligible for free or reduced-price meals at school
CalFresh (SNAP) verification
A copy of last year's tax return

File upload

Emergency Contact

Name, Phone Number, and Relationship to Student*

Consent

I, the undersigned parent/guardian, give permission for my child to participate in tutoring sessions with Aspire Education Alliance (AEA). Or as a 18 or older student, I consent to receive services from AEA. Type yes or no.*

Print Name*

Signature

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Date*

Month

Day

Year