Dragonfly Education Enrollment Form
Client Information:
Date
| Parent/Student | Parent/Student |
| Name: | Name: |
| Phone/Mobile: | Phone/Mobile: |
| Email: | Email: |
| Address: | Address: |
| Does tutoring take place at this address? | Does tutoring take place at this address? |
| Student Name: | School: | Age: | Grade: | Area of Tutoring: |
| | | | |
| Phone/Mobile: | Email: | Birthday: | Teacher(s): |
| | | |
| Sunday | Monday | Tuesday | Wednesday | Thursday | Friday | Saturday |
| | | | | | |
| Student Name: | School: | Age: | Grade: | Area of Tutoring: |
| | | | |
| Phone/Mobile: | Email: | Birthday: | Teacher(s): |
| | | |
| Sunday | Monday | Tuesday | Wednesday | Thursday | Friday | Saturday |
| | | | | | |
Sessions per week and session lengths are estimates and can be altered with agreement from your tutor. If the homework is difficult or a test is coming up, ask for more time. If the tutor's schedule is open, they're happy to help.
| Sessions/Week: | Session Length: | Block of Hours: | Rate/Hour: | Materials Fee: | Registration Fee: |
| | | | | |
| Payment Method: | Payment Option: | Number of Payments: | Payment/Monthly Payment Rate: |
| | | |
NOTE 1: Monthly payment plans are equal installments and do not reflect the hours used. Registration and material fees will be added to the first payment and are non-refundable.
| Name of Card Holder: | Card Number: | Expiration: | CSV/CVV: |
| | | |
NOTE 2: To cover the cost of credit card acceptance, we pass on a 3% credit card fee. This fee is not more than the cost of accepting these cards. There is no fee for debit cards.
