TUTORING ASSESSMENT FORM

PERSONAL INFORMATION OF CHILD/YOUTH

Name of Child/Youth *

First

Last
Name of Parent(s)/Guardian *

First

Last
Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone # *

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Cell Phone # *

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Age *
Gender *
Grade/Highest Level of Education *
 Elementary 
 High School 
 College 
 University 

GENERAL INFORMATION

What subject do you need help in? Please check the appropriate box.
English
 Select 
Enter English Grade Level
Math
 Select 
Enter Math Grade Level
French
 Select 
Enter French Grade Level
Computer
 Beginner 
 Intermediate 
 Advance 
What computer software do you know or want to learn?
Other
Do you have any goals that you want to achieve?
Have you received help in this subject before?
What grades do you receive in this subject?

*PLEASE NOTE: It would be beneficial to provide a copy of your child's last report card.

Signature: Name of Parent/Guardian *
Check to authorize signature *
 Check 
Signature: Name of Child/Youth *
Check to authorize signature *
 Check 
Date *

MM
/
DD
/
YYYY
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