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Ensure Success Services Tutorials
Registration Form
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* Indicates required question
Email
*
Your email
Student Name
*
Your answer
Age
*
Your answer
Grade Level
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
School Name
*
Your answer
Teacher's Name
*
Your answer
Your Name
*
Your answer
Preferred e-mail address
*
Your answer
Select the tutorial program you are enrolling your student in.
*
After 3 - Oak Forest Elementary
Which subject(s) will your student receive tutoring in?
*
Math - Tuesday 3:15-4:00
Reading/Language Arts - Thursday 3:15-4:00
Both (please email
thesuccessexperience@gmail.com
to get approval for this option)
Option 1
Clear selection
Tell us more about your decision to enroll your student in tutorials.
Your answer
How did you hear about us?
*
Your answer
Media Release
*
I agree to allow my student to be photographed or recorded during their session for the purpose of training and/or promotional material.
Yes
No
Required
Would you be willing to submit a testimonial about your experience with us?
*
Yes, I would love to share how awesome you guys are!
No, thanks. I'd like to keep you all to myself.
I understand that payments must be made prior to the start date if paying in full or before the 1st and 8th week of sessions if making a split payment. I further understand that payment must be made in order for my student to attend sessions.
*
Yes
Required
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