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:_______________________