Parents’ or Guardians’ Names
5530 Chelsen Wood Dr
Primary Phone #
Work Phone (Mom)
Parent’s Contact Cell phone
School student is attending now (if applicable)
In what area(s) of academics are you seeking assistance?
(If school course) Textbook Title
DC History and DC Honors Anatomy
If E-class and/or online textbooks, note here your USERID
I do not
(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:
Sat. Morning Afternoon, Sun. Afternoon
How did you hear about Total Learning Concepts or who referred you?
Conference dates and times:
Final Exam Review Class Course:
$50 deposit only if student is already enrolled for this school year = $50