Tutoring Services On-Line Registration Form

Please note: This form is for on-line registration only. To complete the registration form manually and to see the fee structure, download and print a copy of the form at http://www.aclctutoring.com/forms/Registration Form Tutoring Services.pdf

Please complete this entire form for each child applying to the program. Once you start the application, it is advised to follow through and complete it, as information you enter will not be sent to us until you hit the "Submit" button on the last screen. DO NOT USE YOUR BROWSER BACK OR FORWARD BUTTON WHILE FILLING OUT THE FORM. Once completed, a follow-up letter will be sent confirming your application and registration status.

Click to start the application process.

Student Information

First Name		Last Name
Age	Gender	Date of Birth (xx/xx/xxxx)
Current School		School's Address	Grade in September
Student Health Concerns (i.e. Allergies):
Subject to be tutored in:
What were the results of your child's last examination in Mathematics?			What were the results of your child's last examination in English Language Arts?
Is your child on an IEP?
Does your child have any learning disabilities?			Is so, please explain:
What would you like your child to be able to do at the end of the program?			Is there any other pertinent information that we should know?
Student's Special Talents:			Student's Favorite Pastimes:
Spoken Languages:

Parent/Guardian Information All correspondence will be sent to Parent/Guardian First Name Last Name Relationship To Student Street Address City State Zip Home Phone Cell Phone Work Phone Fax Email

Authorized Pick-Up Information (Other than Parent/Guardian) Contact #1 - MANDATORY Full Name (1) Relationship to Student (1) Street Address (1) City (1) State (1) Zip (1) Home Phone (1) Cell Phone (1) Work Phone (1) Email (1) Contact #2 - MANDATORY Full Name (2) Relationship to Student (2) Street Address (2) City (2) State (2) Zip (2) Home Phone (2) Cell Phone (2) Work Phone (2) Email (2)

Availability

Select the times your child will be able to attend tutoring. Please select at least three time slots so that we can better accommodate your child. Note the staff at ACLC will do their best to accommodate your available time; however, there is no guarantee.
Monday (PM) 2:00 - 4:00 3:00 - 5:00 4:00 - 6:00 5:00 - 7:00 6:00 - 8:00	Tuesday (PM) 2:00 - 4:00 3:00 - 5:00 4:00 - 6:00 5:00 - 7:00 6:00 - 8:00	Wednesday (PM) 2:00 - 4:00 3:00 - 5:00 4:00 - 6:00 5:00 - 7:00 6:00 - 8:00
Thursday (PM) 2:00 - 4:00 3:00 - 5:00 4:00 - 6:00 5:00 - 7:00 6:00 - 8:00	Friday (PM) 2:00 - 4:00 3:00 - 5:00 4:00 - 6:00 5:00 - 7:00 6:00 - 8:00	Saturday (AM /PM) 9:00 - 11:00 10:00 - 12:00 11:00 - 1:00 12:00 - 2:00 1:00 - 3:00 2:00 – 4:00
Other Times: (Please indicate any other time that you child might be available for tutoring)

Tutoring Services Enrollment Information

Monday - Friday	First-time Pre-pay Customer		Pre-pay Customer
		Group Rate:		Group Rate:
		On-Site - $256/Month		On-Site - $346/Month
		Off-Site - Not Available		Off-Site - Not Available
		One-to-One Rate:		One-to-One Rate:
		On-Site - $420/Month		On-Site - $520/Month
		Off-Site - $441/Month		Off-Site - $541/Month

*1st Time pre-pay customers save $100 off the first 2-months regular service rate.

Your Total Cost:

Payment Information

All payments must made in full prior to the start of the program. Checks should be made payable to ACLC with the child’s name in the memo line. Payments must be received within 5 business days of submission of the enrollment form. The enrollment form will not be processed until payment is received. Mail to: ACLC, 1107 Washington Street, Dorchester, MA 02124

	Payment Method (required): Choose One:

Enrollment Agreement

I understand that this registration form must be completed in full and accompanied by the full tuition payment.
Tuition for each month is due by at least 5 business days before the start of the new month.
There will be no refund for missed days.
If for any reason your child is unable to attend, a minimum of 24 hours notice of absences must be given.
Each student is allowed up to 3 unexcused absences.
A minimum attendance of two hours per week is required.
Students are expected to complete and turn in all assignment at the next session. The student should work independently as much as possible on their assignment(s).
I understand that it is my responsibility to bring any special concerns about my student to the director's attention upon registration.
Each student is required to arrive on time for each session, as there are other students scheduled after him/her. The student should be picked up no later than 10 minutes after a session ends. In the case of an emergency, please call 617-391-0270.
ACLC reserves the right to withdraw any student when, in the director's judgment, the student’s and/or family's behavior interferes with the rights and/or safety of others, the smooth functioning of the program, or violates the program's principles of conduct.
During the program, staff members and/or professional photographers take photos and videos for marketing purposes which may include the child(ren) listed on this registration form. Parents/guardians may refuse any or all commercial use of photos and videos related to specific children, provided that a written request is received by the director prior to the start of the program.

Enrollment Agreement Acceptance

I accept (Required)

How did you hear about our service?

Please identify which/who: