Parents’ or Guardians’ Names
4020 Red Canoe Bend
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?
Physical Science and Social Studies
(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?
Currently for Algebra I and Physical Science
Please circle days and times when this student can attend sessions:
Mon. Afternoon Evening, Tues. Afternoon Evening, Wed. Afternoon Evening, Thurs. Afternoon Evening, Fri. Afternoon, Sat. Morning Afternoon, Sun. Afternoon
How did you hear about Total Learning Concepts or who referred you?
Older son attended
Conference dates and times:
Final Exam Review Class Course:
$50 deposit only if student is already enrolled for this school year = $50