Ann's Christian Learning Center

GroupWise Intake Form

Registration Form

Parent's Information:
Parent's Name:	First:
	Last:
	Relationship:
Street Address1:
Street Address2:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Fax:
Email Address:
Student's Information
Student's Name:	First:
	Mid. Initial(s):
	Last:
Age:		Male:	Female:
Date of Birth (mm/dd/yyyy):
Name of School:
Grade:

Student's Learning Information

Subject(s) of Difficulty:		1)
		2)
		3)

Name of School-day Teacher(s) in:		Math:
		English:
Email Address of School-day Teacher(s) in:		Math:
		English:
Is your child on an IEP? (select yes or no):		Yes	No
Does your child have any learning disability?
If yes, please explain:

What were the results of your child's last examination in:		a) Math
		b) Reading

Is there any additional pertinent information that we should know about the student, including any food allergies?
Student's Special Talents:
Student's Favorite Pastimes:
Spoken Languages:

Persons authorized for pick-up:
1) Name:
Relationship to Student:
2) Name:
Relationship to Student:
3) Name:
Relationship to Student:
How did you hear about our service?

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:
Monday (PM)	Tuesday (PM)	Wednesday (PM)
2:00 - 4:00	2:00 - 4:00	2:00 - 4:00
3:00 - 5:00	3:00 - 5:00	3:00 - 5:00
4:00 - 6:00	4:00 - 6:00	4:00 - 6:00
5:00 - 7:00	5:00 - 7:00	5:00 - 7:00
6:00 - 8:00	6:00 - 8:00	6:00 - 8:00

Thursday (PM)	Friday (PM)	Saturday (AM & PM)
2:00 - 4:00	2:00 - 4:00	9:00 - 11:00
3:00 - 5:00	3:00 - 5:00	10:00 - 12:00
4:00 - 6:00	4:00 - 6:00	11:00 - 1:00
5:00 - 7:00	5:00 - 7:00	12:00 - 2:00
6:00 - 8:00	6:00 - 8:00	1:00 - 3:00
		2:00 - 4:00

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