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Student Information

Your information will be kept private and confidential.

Student First Name:*

Student Last Name:*

Age:*

Gender:*

Student Cell:*

Grade:*

Year of High School Graduation:*

Current School Name:*

Previous School name(please include years attended):

Student's Email:*

Address :*

Address:

Zip Code:*

State:*

City:

Timezone:

Tutor Personality Preference:

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

Tutor Gender Preference:*

Session Length (hours):

Referred By:

Whom May We Thank for This Referral:

Do you wish to receive text notification of session reminders?

To Which Cell Phone Should Text Reminders Be Sent?

Parent Details

Parent/Legal Guardian Details

First Name*

Last Name*

Relationship to Student:*

Parent/Legal Guardian Self Other (please specify)

Relationship to Student:

Email:*

Parents Address:*

Parents Address:

Parents Zip code:*

Parents State or Province:*

Parents City:*

Preferred Method of Communication:*

Please select the local branch to which sessions will be delivered :* If your location is not listed below, please select OTHER, as sessions can be delivered nationwide.

Austin
Boston
Dallas
Denver
Fort Bend County
Greater New Orleans
Houston
The Woodlands: Kingwood/Humble/Spring
Any Other U.S. location

Preferred Method of Tutoring Delivery:*

Type of Tutoring (Can Select More Than One)

Academic Tutoring
Remote Learning Support
College Counseling
Diagnostic and Skills Assessment
Test Preparation Tutoring

If tutoring is for test preparation (ISEE/ACT/SAT), please upload any previous test scores here (Only Pdf, Doc, Docx files are accepted)

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 Faces:*

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

Top 3 Tips for Teaching Effectively:*

Reason for Tutoring/Other Information:

Intended Tutoring Start Date*

Student Availability

MEDICATIONS

Medications name 1:

Medications Dose 1:

Medications name 2:

Medications Dose 2:

A-HTS COVID Liability Family Waiver

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

Please sign and date below representing that you have understood the risks, align with our safety protocols and agree to abide by them.

Date : 03-30-2023

On Behalf of Minor Child(ren):*

Signed:*

CSD HOLDINGS, INC DBA AT-HOME TUTORING SERVICES

Beginning Date:*

At-Home Tutoring Services will provide tutoring services to:*

Payment Policy

Professional Fees (Per Hour)
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 Per 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
Online Executive Functioning (Director)	$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 cancelled within 24 hours regardless of reason will be charged a fee of 100% session rate.

Professional Fees (Per Hour)
Academic Tutoring (Standard)	$65
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)

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

Video/Audio Tape Consent

Parent/Legal Guardian Signature:*

On behalf of the minor child:*

Date Signed:*

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

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

Client's parent/guardian verification:*

Date:*

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.

Card Type:*

Card Number:*

Expiration Date:*

Card/Account Holder's Name:

Billing Address

Address:*

Zip code:*

State or Province:*

City:*

Email Address to Send Receipts:*

Login Details

Username: *

Password: *

Password again:: *

Signature

Client's parent/guardian verification:*

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

Date Of Signature:*