Client Registration

Please complete this form in its entirety.

Click here to download the form in PDF format.

Section I: Client Information

First Name
Last Name
Birth Date
Grade Level
School
School System
Home Number
Work Number
Mobile Number
Occupation / Employer / Highest level of education
Email addresses

Section II: Responsible Party Information

Parent / Guardian (1)
Relation to Student (1)
Address (1)
Home Number (1)
Work Number (1)
Mobile Number (1)
Occupation / Employer / Highest level of education (1)
Email addresses (1)
Parent / Guardian (2)
Relation to Student (2)
Address (2)
Home Number (2)
Work Number (2)
Mobile Number (2)
Occupation / Employer / Highest level of education (2)
Email addresses (2)
Names of individuals authorized to chaperone student (other than parent / guardian)
Chaperone Name (1)
Chaperon Relationship (1)
Chaperone Name (2)
Chaperon Relationship (2)

Section III: Emergency Contacts

Emergency Contact Name (1)
Emergency Contact Relation to client (1)
Emergency Contact Home Number (1)
Emergency Contact Work Number (1)
Emergency Contact Mobile Number (1)
Emergency Contact Name (2)
Emergency Contact Relation to client (2)
Emergency Contact Home Number (2)
Emergency Contact Work Number (2)
Emergency Contact Mobile Number (2)

Section IV: Information on Exceeding the Mark

How did you hear about us?
What has encouraged you to want to receive services from ETM?

Section V: Requested Services

Tutoring is provided in your home or other location agreed upon by you and your tutor. Please be mindful matches are made based on the address you provide in the application. While every effort will be made to ensure a match of your child with a tutor, if we are not able to match you with a tutor in your area, we will keep your application on file until a tutor becomes available. If you choose one of our other programs for your child or for yourself, a schedule will be provided of class dates upon receipt of your application.

Programs

Tutoring for Success
Early Childhood Education
Parents to Teachers
Parent Focus
Launch to Success
Healthy Minds
Faith Building
Days for tutoring (include hours next to day checked)
Monday
Monday Hours
Tuesday
Tuesday Hours
Wednesday
Wednesday Hours
Thursday
Thursday Hours
Friday
Friday Hours
Saturday
Saturday Hours
Sunday
Sunday Hours
Hobbies / Interests of the client that you are willing to share
If you are requesting tutoring for your child, please check grade level below (skip this section if not receiving tutoring services)
K-3
4-5
6-8
9-12
Please list subject areas below (describe any specific difficulties your child is having in the subject areas)
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If you're interested in getting involved with ETM, please contact us at info@exceedingthemark.org.