Registration - Aretha Gordon & Associates

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Tutoring Registration Form

Section 1: Student Information

Student Full Name

School Name

Grade Level

Age

Section 2: Parent/Guardian Information

Parent/ Guardian Name

Relationship to Student

Your Phone

Email Address

Section 3: Emergency Contact

Subjects Needed

Math Only

Reading Only

Reading and Math

Preferred Tutoring Format

In-Person

Online

Preffered Days

Monday

Tuesday

Wednesday

Thursday

Saturday

Summer sessions

Section 4: Additional Information

Learning Goals or Areas Of Concern

Medical or Learning Conditions We Should Know About

Section 5: Consent

Emergency Contact Name

Relationship to Student

Phone

Parent/Guardian Consent

I give permission for my child to participate in tutoring sessions and understand that all reasonable precautions will be taken to ensure a safe and productive learning environment.

Regular Tutoring Sessions

Summer Promotional Pricing

Summer Boost Program: 6 sessions per subject. Each session lasts 60 minutes. (Monday through Thursday) Sessions are held from 9:00 AM to 2:00 PM

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Select Summer Session

Total

Credit Card

Card Details

Cardholder Name

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Durham, North Carolina
919-394-2032
arethagordon2@gmail.com

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