Student Information

Student Name *

Age (Session Start) *

Birthdate

Language *

Spanish

Mandarin Chinese

Please provide possible options for day of week and time for private classes. *

Any medical conditions of the student that we should be aware of? If none, please write none. *

Please use this space to tell us if the student has had any exposure to the foreign language. If so, please indicate how many years. If student is enrolled in a language class in school, please indicate which level.

Please use this space to tell us what outcome you are expecting at the completion of the tutoring sessions. *

Parent(s)/Guardian(s) Name *

Address *

Country

City

State

Zip code

Mobile Number *

Alternate Number *

Email--please provide an address that is checked often. *

How did you hear about us? If you were referred, please list referrer's name.

Liability Agreement/Review of Policies

Signature *

Date

Signature *

Date *

Payment Information

How Would You Like to Pay

(please select one of the following) First monthly payment must be made prior to the start of services. Subsequent payments must be made monthly prior to the 1st week of each month.

Payment Options

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Private Student Registration

Student Information

Liability Agreement/Review of Policies

Payment Information