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:_______________________