Student Name *

First Name

Last Name

Student Birthday *

MM

DD

YYYY

Gender *

Male

Female

I would like to enroll my child for the following tutoring subjects: *

(Check all that apply)

Basic Reading

Basic Math

Pre Algebra

Algebra

Algebra 2

Geometry

Primary Parent Name/Legal Guardian #1 *

First Name

Last Name

Relation to Student *

Father

Mother

Guardian

Stepfather

Stepmother

Grandparent

Other

Primary Phone #1 *

(###)

###

####

Primary Parent Name/Legal Guardian #2

First Name

Last Name

Relation to Student

Father

Mother

Guardian

Stepfather

Stepmother

Grandparent

Other

Primary Phone #2

(###)

###

####

Primary Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Does your child have any food or environmental allergies? *

Yes

No

I agree to allow my child’s name and photograph to be included in Cedar Hill Academy publications and in information shared with the media and\or social media accounts. *

Yes

No