Ann's Christian Learning Center

Please fill out the form carefully.

Student Information
First Name:
Last Name:
Grade:

Services Offered:
	Structure of Session(s) - Please note that the structure of the session depends on the service(s) you have selected. You can however select individual tutoring for any service offered.
Structure of Session(s):	Individual	Group
Subject (s) to be tutored in:			Supplemental Support in Math (grades K - 8)
			Supplemental Support in English (grades K - 8)
			Targeted Instruction in Math (grades K - 8)
			Targeted Instruction in English (grades K - 8)
			Reading (Phonics) (grades K - 3)
			Writing (grades 2 to 8)
			MCAS Prep - Math (grades 3 - 8)
			MCAS Prep - English (grades 3 - 8)
			ISEE Prep (grades 5 -8)

IEP:	Yes: No:
Teacher Name:
Teacher Email:
School:

Parent/Guardian Information
First Name
Last Name:
Relationship to Student:
Work Phone:
Home Phone:
Cell Phone:
Email address:

METCO Information
Name of District:
Director's First Name:
Director's Last Name:
Work Phone:
Cell Phone (optional):
Email Address:

Terms of Payment (Please check the term that you will be paying by)
Prepay Monthly
Prepay Quarterly (24 hours per subject)
Net 30days
Purchase Order (PO may be faxed to 617-287-2878):
Hours of tutoring commitment:

Bill Information (if not paying by Purchase Order)
Company Name:
Contact Name:
Street Address:
City:
State:
Zip:

Would you like a return phone call to confirm reciept of this information:
Yes: No:
Additional Information/Comments: