STUDENT:  
(Parents):  
Address:  
City:   NY zip:________
Phone(s):  
SUBJECT:  
School/Grade:  
Final/Test-Day:  
Previous
scores:
 
 
Tutor/Agency/*:  
Date Day Time Signature Notes / Next * Hrs.
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
Availability:
M T W H F Sat. Sun.
             
    Signature below acknowledges the following conditions:
  • Fee for returned check:   $ 30.00
  • Rate base on recommended hours:   minimum of __1__ hours per week until ________.
  • One hour charged for missed lesson - unless cancelled by 3pm previous day.
Parent Signature:_______________________