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*

Parent/Legal Guardian*

First Last

Relationship to Student*

Parent/Legal Guardian
Self
Other (please specify)

Relationship to Student*

cell*

Email*

Address*

City*

Zip Code*

Preferred Method of Communication*

Phone
Text
E-Mail

Preferred Method of Tutoring Delivery:*

In-Person
Virtual Tutoring in our Online Classroom
Either

Type of Tutoring Desired (Can Select More Than One)*

Academic Tutoring (after school hours)
Remote Learning Support (during school day to assist with virtual learning)
Test Preparation (ISEE Exam)
Test Preparation (ACT, SAT or other)
College Counseling
Diagnostic and Skills Assessment

Note: All ISEE students must enroll in our online test preparation program.*

I agree to the $99 online program fee.

All A-HTS ISEE students MUST have an account with our online ISEE program at a cost of $99 per year.

Desired Total Hours Per Week*

Superintendent Level: 10 hours
Principal Level: 5 hours
Teacher Level: 3 hours
Other - please call us to customize an option for you

Will Tutoring be Part of a Group or Learning Pod?*

Yes
No

Please List the Names of the Other Parent(s) in the Group*

Subjects for tutoring*

Current Letter/Number Grade

Subjects for tutoring

Current Letter/Number Grade

Subjects for tutoring

Current Letter/Number Grade

Please list some academic goals for your student*

Describe the Challenges Your Student Faced While Remote Learning:*

Are You Interested in Your Student Taking a Skills Assessment ($99 fee per student)?*

Yes
No

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

Official Testing Date(s)

Tutor Gender Preference*

Female Only
Male Only
Open/No Preference

Tutoring Personality Preference*

Top 3 Tips for Teaching Your Student Effectively*

1)	2)	3)

Reason for Tutoring/Other Information

Intended Tutoring Start Date*

Number of Sessions/Week*

Session Length (hours)*

Referred By:*

Whom May We Thank for This Referral?*

Availability

Days

Available Times (Sundays)

Available Times (Monday)

Available Times (Tuesday)

Available Times (Wednesday)

Available Times (Thursday)

Available Times (Friday)

Available Times (Saturday)

Ideal Schedule

Days

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

CSD Holdings, Inc dba At-Home Tutoring Services

Beginning

Date*

At-Home Tutoring Services will provide tutoring services to

*

Please enter the student's first and last name

Payment Policy

Professional Fees (Per Hour)
Academic Tutoring (Standard)	$75
Academic Tutoring (Mid-Tier)	$85
Academic Tutoring (Subject Specialist)	$110
Group Academic Tutoring	15% Off Published Rates Above
Edmentum: Exact Path Supply Fee	$99 Per Student/Year

Test Preparation (Standard)	$85
Test Preparation (Mid-Tier)	$110
Test Preparation (Director)	$150
Piqosity Supply Fee	$99 Per Student/Year

Admissions (Consultant Level)	$110
Admissions (Director Level)	$150
CounselMore Supply Fee	$99/Student/Year
(Auto-renews every June 1)

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 cancelled within 24 hours regardless of reason will be charged a fee of 100% session rate.

Acknowledgement*

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

Acknowledgement

Video/Audio Tape 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.

Please read the following and, if you agree with its terms, sign where indicated below:

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.

Parent/Legal Guardian Signature*

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

On behalf of the minor child*

Type your student's name in the field above

Date Signed*

Acknowledgement*

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

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.

Acknowledgement*

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

Client's parent/guardian verification*

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

Date*

MM

DD

YYYY

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*

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/guardian verification*

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

Date of Signature*

MM

DD

YYYY

New Student Form

Availability

Ideal Schedule

Medications

CSD Holdings, Inc dba At-Home Tutoring Services

Video/Audio Tape Consent

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