STUDENT:  
Address:  
City:   NY zip:________
Phone, email:  
Parents:  
SUBJECT: o  
School/Grade:  
Final/Test-Day:  
Previous scores:  
# _____ @    
Date Day Time Signature Notes Hrs. Next
2016/              
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
Availability:
M T W H F Sat. Sun.




           
    Signature below acknowledges the following conditions:
  • One hour charged for missed lesson - unless cancelled via telephone 24 hours in advance.
  • Rate based on   _1.5_ hours tutoring per school week until __________.
  • Fee for returned check:   $ 30.00
    Parent Signature:_______________________