Parents’ or Guardians’ Names
2600 Crescent Moon Ln
Primary Phone #
Work Phone (Mom)
Parent’s Contact Cell phone
School student is attending now (if applicable)
Providence Christian academy
In what area(s) of academics are you seeking assistance?
(If school course) Textbook Title
If E-class and/or online textbooks, note here your USERID
(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?
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?
Conference dates and times:
Advanced Placement National Test Prep Course:
$50 deposit + $35 returning student fee = $85