Registration Form

ABBA Educational Consultants Registration Form

Date: ______________________

Student Information

Student name: _______________________

Student: Grade: ______________________

Student Age: ________________________

Student Birth date: ___________________

Family Information

Your name: ______________________________

Relationship to student: _____________________

Telephone number(s) e.g. home, work, cell:

__________________________________

Your address: __________________________________

Student address (if different than yours)

_________________________________

Emergency contact info (other than you)

__________________________________

School Information

Student’s School: __________________________________ Telephone Number: _____________________

Student’s Teachers’ Names: Math____________________ Reading___________________

School/Student Counselor Name: ________________________________

Was tutoring recommended by student’s school or teacher? ____________

Last report card grade: Reading _______ Math: _______

Last MSA Grades: Reading: __________ Math: _______

Did student receive a progress report in math this year? _______________

Does student have an IEP? _______________ 504 Plan? ____________

Has student been diagnosed with a learning disability, ADD, ADHD, other? _________

§ If yes, what is the clinical term used? __________________

§ Is student on medication for above? ___________________

General Information

§ What would you like student to be able to do as a result of attending this program
that he or she is not doing now?

_______________________________________________________________________

§ Do you have any learning concerns about your student? If yes, please explain.

______________________________________________________________________

_______________________________________________________________________