Custom Instruction Request

Adult Contact Name

Adult Contact Email

Adult Contact Phone

Time Zone

Please let us know what time zone you live in.

Student Name or Group Name

Age of Student(s)

Grade of Student(s)

Subject Area

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Starting Period

When would you like to start services? There are four quarters per school year and an additional summer period. Please select the appropriate period from the list below.

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Service Type

Are you seeking private course instruction, supplemental tutoring, or semi-private instruction (for multiple students)?

Preferred Tutor

If you'd like to request a specific tutor, please choose his or her name from the list below.

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Background

Describe your student's background in this area of study or discipline. (e.g. years of study, curriculum level, texts used, etc.)

{name}

Curriculum

Are you interested in using specific texts/curriculum in the tutoring sessions? If so, which?

{name}

Goals

What are your tutoring goals for your student?

{name}

Evaluations

Has your student had any professional, academic evaluations that would be relevant for your instructor to know as a tutoring plan is being developed? Please describe below.

{name}

Learning Differences

Do you have any undiagnosed learning concerns that would be relevant for your instructor to know as a tutoring plan is being developed? Please describe below.

{name}

Schedule

Please describe your scheduling preferences, including preferred start date. Are you planning any trips or vacations during the current purchasing quarter? Please describe below.

{name}

Comments

Any additional comments you'd like to share with us?

{name}

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