Tutoring Center Application

Student's first name:  Last name:

Student's nickname:

Date of Birth:  Age:  Sex:  Grade:

School: City:  State:   -- select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Parent 1 : -- title -- Mr. Mrs. Ms. Miss Dr.   First:  Last:

Parent 2 : -- title -- Mr. Mrs. Ms. Miss Dr.   First:  Last:

Lives with: Parent 1 Parent 2 Both Other:

Primary email address:

Parent 1

Street address:

City: ,  State:   -- select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Home phone: Work phone:

Cell phone:

Parent 2

Street address:

City: ,  State:   -- select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Home phone: Work phone:

Cell phone:

Person responsible for fees (if different from above):

Name: Phone:

Street address:

City: ,  State:   -- select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Has your child been identified as having ADD or ADHD? No Yes

Is your child currently on any medications? If so, please list:

On what would you like tutoring to focus?

Is there anything a tutor should know about your child to help us design a successful
tutoring session?

Has your child had a psycho-educational evaluation in the last 3 years? No Yes
IF SO, PLEASE PROVIDE US WITH A COPY AT THE MAILING ADDRESS BELOW.

Please share with us how you learned of AIM~Academy In Manayunk’s Tutoring Center:

AIM~Academy In Manayunk Tutoring Center
1200 River Road
Conshohocken, PA 19428