Tell Us About Your Child: Student's name Parent's name(s) Address Cross streets (for in-home tutoring) City Zip code Home Phone Parent Work Phone Parent Cell Phone Parent's Email Birthdate Grade School How did you hear about On-Track? please select friend or relative ad (magazine, newspaper) Google search other online search school administrator/teacher physician/psychologist/neuropsychologist other Preferred location of tutoring: please select at home at a library or other public place at Notre Dame Prep during study hall at the On-Track office (For Notre Dame Prep students) study hall period : please select A period B period C period D period E period F period G period H period none Subject(s) to be tutored: please specify Please describe your child's personality, activities and interests, and any diagnosed or suspected learning challenges: Please list preferred days/times you'd like tutoring, and any time constraints that you or your child has How many days per week would you like your child to receive tutoring? please select 1 2 3 more What age tutor and what type of personality would work best with your child? Would your child prefer a male, female, or either? Please list any other comments and concerns here:

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