Today’s Date
03-09-2021
Student’s Name
Jack Clements
Birthdate
05-25-2003
Parents’ or Guardians’ Names
Fiona Clements
Street Address
2600 Crescent Moon Ln
City
Snellville
State
GA
Zip
30078-7766
Parent/Guardian E-mail
clementsfee@gmail.com
Primary Phone #
4044092770
Employer(s)
self
Work Phone (Mom)
4044092770
Parent’s Contact Cell phone
4044092770
Work Phone (Dad)
School student is attending now (if applicable)
Providence Christian academy
Grade Level
12
In what area(s) of academics are you seeking assistance?
AP physics
(If school course) Textbook Title
ISBN#
If E-class and/or online textbooks, note here your USERID
PASSCODE
PARENT’S INITIALS
FC
(If virtual sessions) SKYPE contact ID & phone #/email
If the student has any learning differences about which we should be aware, please explain
Have you ever used a tutor or learning center before?
yes
If yes, who, when, and in what area of academics?
Please circle days and times when this student can attend sessions:
Fri. Afternoon, Sat. Morning Afternoon, Sun. Afternoon
How did you hear about Total Learning Concepts or who referred you?
drive past
Conference dates and times:
any
Advanced Placement National Test Prep Course:
$50 deposit + $35 returning student fee = $85