REGISTER FOR TUTORING! Parent Or Guardian Name * First Last Cell Phone Number: * Email Address * Address * Best way to contact you: * Students Name * First Last Grade: * Current School: * Emergency Contact * First Last Cell Phone Number: * How did you hear about LPFS tutoring program? * For which academic area are you seeking tutoring: * How is your child’s academic behavior in the classroom? * Are there any siblings or family members that struggle with reading, writing, or spelling? * YES NO Please explain: * Has your child received tutoring from school ? * YES NO Has your child received private tutoring? * YES NO Is your child currently receiving Title 1 or ESE (Exceptional Student Education services? * YES NO Has your child ever been retained? * YES NO Grade retained: Does your child currently have an IEP? * YES NO If yes, what is the primary exceptionality? * Has your child been psychologically evaluated? * YES NO If yes, Where and Date: Parent/Guardian Agreement - Please Click The Box To Agree * I give Learning Partners for Success permission to obtain academic information from my child’s School Records. I give Learning Partners for Success permission to communicate with officials (ie: teachers, counselors, social workers, etc.) I give LPFS permission to take photographs for promotional purposes. I understand that I must provide LPFS with my child’s report card after each grading period. I understand that I must provide LPFS with my child’s state standardize scores from the previous academic year at the beginning of each program year. I understand that I will be responsible for transportation to and from the program and that LPFS and/or their representatives may not transport my child at any time during the program. I understand that failure to promptly pickup my child from each session could result in dismissal from the program. I understand that if my child will be absent, I must contact the LPFS office before 2:00 pm. I understand that if my child has an inexcusable absent twice without notification they may be terminated from the program. I CONSENT TO ALL OF THE FOLLOWING TO BE PERFORMED BY LEARNING PARTNERS FOR SUCCESS * YES PARENT OR LEGAL GUARDIAN PRINT NAME * First Last Date / Time * BOOK YOUR SESSION TODAY!