Student Services - Client Registration Form

Legal Guardian

Salutation

First Name*

Last Name*

Email*

Phone Number*

Street address*

City*

State/Region*

Zipcode*

Preferred language*

Student Information

Student's First Name*

Student's Last Name*

Date of birth*

Gender

School

If your student is being homeschooled, type Homeschool

Current Grade Level Placement*

Academic Subjects*

Select ALL that apply

Mathematics (ages 5-14)

Life Skills (ages 12-21)

Reading (ages 5-14)

Writing (ages 5-14)

Frequency of Services (Weeks)*

Select your desired frequency of services

Duration of Services (Min.)*

Select the duration of how long you want tutoring sessions to be. Each tutoring session duration comes at different rates.

Student Plan Status*

Select the Student Plan your student has. If your student does not have a Student Plan and is currently being evaluated, select Evaluation Phase. ELL plans are for students who are learning English as an additional language to their home language. RTI/MTSS plans are intervention plans. If your student does not have plan, select N/A.

Student Records

Upload any student records to support our team with determining your student's strengths and needs. You may include up to 3 records (report cards, assessment scores, etc.)

Authorization

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records.

By clicking this box, you authorize Realized Curriculum Solutions and its employees and contractors to view your student's educational records for the purpose of receiving instructional services.

FERPA Authorization*

Reference*

How did you learn about us?

Signature *

Date*

Month/Day/Year