Student's Name*

First Last

Age

Grade*

Year of High School Graduation*

Current School Name*

Previous School name: (please include years attended)

Student's Email*

Student's Text Number

Parent/Legal Guardian*

First Last

Relationship to Student*

Parent/Legal Guardian
Self
Other (please specify)

Relationship to Student*

Parent/ Legal Guardian Cell*

Parent/Legal Guardian Email*

Tutoring Address*

City*

Zip Code*

Preferred Method of Communication*

Phone
Text
E-Mail

Please select the local branch to which sessions will be delivered*

Preferred Method of Tutoring Delivery:*

In-Person
Virtual Tutoring in our Online Classroom
Either

Type of Tutoring (Can Select More Than One)*

Academic Tutoring
Academic Coaching
Admissions
Test Preparation

Subjects for tutoring*

Current Letter/Number Grade

Subjects for tutoring

Current Letter/Number Grade

Test Preparation Fee Acknowledgment*

Yes

By Selecting "Yes" to the field above I agree to be charged a $99 annual per license fee for an ISEE program (if preparing for an ISEE exam.)

Please List Some Academic Goals for Your Student*

Are You Interested in Your Student Taking a Skills Assessment?*

Yes
No

Skills Assessment Acknowledgment*

Yes

By Selecting "Yes" to the field above I agree to be charged a $99 annual per license fee.

Top 3 Tips for Teaching Your Student Effectively*

1)	2)	3)

Reason for Tutoring/Other Information

Intended Tutoring Start Date

Tutor Gender Preference*

Female Only
Male Only
Open/No Preference

Tutor Personality Preference (May Select More Than One)*

Calm/Reserved
Outgoing
Willing to Move at a Fast Pace
Willing to Move at a Moderate Pace
Detail Oriented
Results Oriented
Funny/Good Sense of Humor
Firm But Kind

If tutoring is for test preparation (ISEE/ACT/SAT), please upload any previous test scores here

Accepted file types: jpg, pdf, Max. file size: 200 MB.

Official Testing Date(s)

Number of Sessions/Week*

Session Length (hours)*

Referred By:*

Whom May We Thank for This Referral?*

Availability

Days

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Available Times (Sundays)

Available Times (Monday)

Available Times (Tuesday)

Available Times (Wednesday)

Available Times (Thursday)

Available Times (Friday)

Available Times (Saturday)

Ideal Schedule

Days

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Ideal Time (Sunday)

Available Times (Monday)

Available Times (Tuesday)

Available Times (Wednesday)

Available Times (Thursday)

Available Times (Friday)

Available Times (Saturday)

Medications

Name

Dosing

Name

Dosing

A-HTS® Policies

CSD Holdings, Inc dba At-Home Tutoring Services

Beginning

Date*

At-Home Tutoring Services will provide tutoring services to

Covid-19 Policy*

The health and safety of our students and tutors has been paramount while we all navigated the consequences of the pandemic.

As guidance from local, regional, and federal authorities appears to recommend that mask-wearing, disinfecting and social distancing be reconsidered especially with vaccinated parties, we are formulating a new safety approach.

For in-person sessions, we are asking each student-tutor pairing to communicate with each other and arrive at a mutually agreeable decision about whether both parties wear a mask or not, stay socially distanced within the session and what disinfecting procedures, if any, should be used.

Please inform the office should you have any issues or questions.

By checking this box, I acknowledge that I have read and understood the information above.

Please Enter Your Child(ren)'s First and Last Name

On Behalf of Minor Child(ren)*

First Last

Payment Policy*

Payment Policy

Academic Tutoring
• Online Academic Tutoring (Standard) $75
• Online Academic Tutoring (Subject Specialist) $110
• In-Person Academic Tutoring (Standard) $85
• In-Person Academic Tutoring (Subject Specialist) $120

• Group Academic Tutoring 15% Off Published Rates Above
• Edmentum: Exact Path Supply Fee $99/Student/Year

Test Preparation
• Online Test Preparation (Standard) $85
• Online Test Preparation (Mid-Tier) $110
• Online Test Preparation (Director) $150
• In-Person Test Preparation (Standard) $95
• In-Person Test Preparation (Mid-Tier) $120
• In-Person Test Preparation (Director) $160
o ISEE Preparation Portal $199/Student/Year
o ACT/SAT Preparation Portal $199/Student/High School Career (One-Time Fee)

College Admissions
• Admissions (Standard) $110
• Admissions (Director) $150
• Guided Path Supply Fee $100/Student/Year
(Auto-renews every June 1)

Academic Coaching
• Online Executive Functioning (Standard) $110
• In-Person Executive Functioning (Standard) $110
• Executive Functioning (Director) $150

Miscellaneous
• Meetings, In-Person Consultations,
School Board Representation (Executive) $350

Any invoices unpaid by the last day of each calendar month are subject to a finance charge/late fee of 1/2% (one-half of one percent) of the invoice balance and all tutoring will be suspended.

Cancellation policy: Any session canceled within 24 hours regardless of reason will be charged a fee of 100% session rate.

By checking this box, I acknowledge that I have read and understood the information above.

Payment Policy*

Payment Policy

Academic Tutoring
• Online Academic Tutoring (Standard) $75
• Online Academic Tutoring (Subject Specialist) $110
• In-Person Academic Tutoring (Standard) $85
• In-Person Academic Tutoring (Subject Specialist) $120

• Group Academic Tutoring 15% Off Published Rates Above
• Edmentum: Exact Path Supply Fee $99/Student/Year

Test Preparation
• Online Test Preparation (Standard) $85
• Online Test Preparation (Mid-Tier) $110
• Online Test Preparation (Director) $150
• In-Person Test Preparation (Standard) $95
• In-Person Test Preparation (Mid-Tier) $120
• In-Person Test Preparation (Director) $160
o ISEE Preparation Portal $199/Student/Year
o ACT/SAT Preparation Portal $199/Student/High School Career (One-Time Fee)

College Admissions
• Admissions (Standard) $110
• Admissions (Director) $150
• Guided Path Supply Fee $100/Student/Year
(Auto-renews every June 1)

Academic Coaching
• Online Executive Functioning (Standard) $110
• In-Person Executive Functioning (Standard) $110
• Executive Functioning (Director) $150

Miscellaneous
• Meetings, In-Person Consultations,
School Board Representation (Executive) $350

Any invoices unpaid by the last day of each calendar month are subject to a finance charge/late fee of 1/2% (one-half of one percent) of the invoice balance and all tutoring will be suspended.

Cancellation policy: Any session canceled within 24 hours regardless of reason will be charged a fee of 100% session rate.

By checking this box, I acknowledge that I have read and understood the information above.

Payment Policy*

Payment Policy

Academic Tutoring
• Online Academic Tutoring (Standard) $75
• Online Academic Tutoring (Subject Specialist) $110
• In-Person Academic Tutoring (Standard) $85
• In-Person Academic Tutoring (Subject Specialist) $120

• Group Academic Tutoring 15% Off Published Rates Above
• Edmentum: Exact Path Supply Fee $99/Student/Year

Test Preparation
• Online Test Preparation (Standard) $85
• Online Test Preparation (Mid-Tier) $110
• Online Test Preparation (Director) $150
• In-Person Test Preparation (Standard) $95
• In-Person Test Preparation (Mid-Tier) $120
• In-Person Test Preparation (Director) $160
o ISEE Preparation Portal $199/Student/Year
o ACT/SAT Preparation Portal $199/Student/High School Career (One-Time Fee)

College Admissions
• Admissions (Standard) $110
• Admissions (Director) $150
• Guided Path Supply Fee $100/Student/Year
(Auto-renews every June 1)

Academic Coaching
• Online Executive Functioning (Standard) $110
• In-Person Executive Functioning (Standard) $110
• Executive Functioning (Director) $150

Miscellaneous
• Meetings, In-Person Consultations,
School Board Representation (Executive) $350

Any invoices unpaid by the last day of each calendar month are subject to a finance charge/late fee of 1/2% (one-half of one percent) of the invoice balance and all tutoring will be suspended.

Cancellation policy: Any session canceled within 24 hours regardless of reason will be charged a fee of 100% session rate.

By checking this box, I acknowledge that I have read and understood the information above.

Video/Audio Tape Consent

Consent

As part of our mission to offer high-quality education, it is often useful for office staff, tutors and
students to review recordings of past tutoring sessions conducted on our virtual classroom. Recorded
sessions help to ensure the delivery of quality instruction, to improve professional standards, and to
advance associated research and training programs. Recordings are used for internal purposes only and
are not distributed or used for marketing or advertising. At-Home Tutoring Services, will undertake to
ensure the anonymity and confidentiality of any recorded student and represents to any party to this
contract that the use of any video and/or audio recordings will be for internal purposes only.

On behalf of my minor child and/or myself, I consent to video and/or audio recordings being made of any tutoring sessions delivered on At-Home Tutoring Services’ virtual classroom platform or other classroom software and to the use of any such recordings for the company’s internal use only.

Acknowledgement

By checking this box, I acknowledge that I have read and understood the information above.

Consent*

At-Home Tutoring Services will try its best to link the client with a tutor that best suits the academic needs, personality, and timely demands of the client. If the client is uncomfortable with a tutor or the manner in which tutor delivers services, At-Home Tutoring Services will make every reasonable attempt to link the client with a tutor that meets the client’s individualized needs. The client further agrees he/she will not directly solicit the services of the tutor employed by At-Home Tutoring Services and will not personally hire the tutor unless such placement is made through At-Home Tutoring Services. At-Home Tutoring Services' tutors will not complete a client's assigned work or papers. The client is responsible for knowing the school's Honor Code as it relates to utilizing outside resources to assist with school work. At-Home Tutoring Services and its tutors are not responsible for knowing each school's Honor Code.

I agree to this policy.

Acknowledgement*

By checking this box, I acknowledge that I have read and understood the information above.

AT-HOME TUTORING SERVICES

AT-HOME TUTORING SERVICES CREDIT CARD AUTHORIZATION FORM

Please fill out and return this form to activate ACH or credit card billing for charges due on your At-Home Tutoring Services account.

Your bank account or credit card will be billed monthly until At-Home Tutoring Services receives written cancellation of service.

Preferred Payment Type*

ACH/E-Check
Credit Card

ACH/E-Check

Bank Name*

Bank Account Type*

Consumer Checking
Consumer Savings
Business Checking
Business Savings
N/A

Routing Number*

Account Number*

Credit Card

Card Number*

Security Code*

Expiration Date (Month & Year)*

Card/Account Holder's Name*

exactly as it appears on account/card

Billing Address*

City

State

Zip*

Card Holder Phone Number*

Email Address to Send Receipts*

Client's parent/ Legal guardian verification*

Type your full name in field in ALL CAPS in the field above

Date of Signature*

*New Student Form

Availability

Ideal Schedule

Medications

A-HTS® Policies

CSD Holdings, Inc dba At-Home Tutoring Services

Beginning

Video/Audio Tape Consent

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