Student Information Form

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Achieve Student Information Form

* Indicates required field

Student Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Student's Current Grade *

Is your child enrolled in any special programs at school? *

Please include information for all parents/guardians that may be dropping off or picking up your child.

Parent/Guardian Name 1 *

First

Last

Relationship *

Parent/Guardian Phone Number 1 *

Parent/Guardian Email 1 (Please provide an email you check regularly) *

Is it ok to text this number? *

Yes No

Parent/Guardian Name 2 *

First

Last

Relationship *

Parent/Guardian Phone Number 2 *

Parent/Guardian Email 2 (Please provide an email you check regularly) *

Please add additional Parent/Guardian Information Here *

Is it ok to text this number? *

Yes No

Services (Please choose all that you are interested in or apply.) *

Ages 5-7 Home school Program Ages 8-14 Home school Program High School Home school Program Music Lessons CSI Math Camp STAAR Bootcamp Individual Tutoring Homework Help Student Success Coaching Group Tutoring Skills Saturday Group Classes Adult ESL Class Child ESL Class Family ESL Class Achieve Typing! Class Technology Readiness Class K-8 Readiness Camp Virtual Tutoring

Subject Matter (Please choose all that you are interested in or apply.) *

Reading Writing Math Science Social Studies Piano Guitar Voice Recorder Flute General Music Amateur Radio ESL Technology Other

Child's Learning Style (Please check all that apply.) *

Visual (learns best by seeing material) Auditory (learns best by hearing the material) Kinesthetic/Tactile (learns best by doing - hands-on)

Is there anything else you think we should know about your child? (Please note that you will also fill out a health form, photo release form, and teacher contact form.) *

By typing my name below, I acknowledge that I have entered all information necessary to help Achieve Learning Center provide the best learning experience for my child. *

Submit

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