Student Registration Form STUDENT REGISTRATION FORM Student Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*FemaleMaleNon-Binary/OtherPreferred PronounsStudent Email* Student CellHome Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SchoolGraduating Year PARENT/GUARDIAN INFORMATIONPrimary Parent First Last Cell*HomeEmail* Secondary Parent First Last CellHomeEmail What kind of tutoring service are you seeking?*Test PreparationAcademic CoachingWriting CoachingSubject TutoringProctored Practice TestWhat type of writing are you interested in improving?* Academic (e.g., term papers or lab reports) Creative (fiction or nonfiction; e.g., short stories, college application essays, etc.) Which test(s) are you preparing for?*SATACTUndecided between SAT and ACTSAT Subject TestsSSATISEE/HSPTGRELSATGMATMCATWhich subject(s)?* Literature US History World History Mathematics (Level 1 or 2) Biology E/M Chemistry Physics Foreign Language Which language(s)?*Upper Level or Middle Level?*Upper Level (entering grades 9-11)Middle Level (entering grades 6-8)Test Date (if applicable) DIAGNOSTIC SCORESPSATReading + WritingMath SATPlease provide the Essay subscores, if applicable. Reading + WritingMathEssay PreACTEnglishMathReadingScience ACTEnglishMathReadingScienceWriting Colleges/grad programs applying to:Please select the desired subjects for tutoring:* Math English History Science Reading Foreign Language Other Other subjectForeign Language:Select any that apply: Dyslexia and/or Dysgraphia ADD/ADHD Executive functioning Processing speed Test anxiety Other Please explain.Writing Sample Drop files here or Accepted file types: pdf, docx, txt, pages. Please submit a writing sample of recent work. Writing samples are used only for assessment, not review or editing.Colleges/grad programs applying to (if applicable):Educational concerns? Please explain.Additional educational concerns? Please explain.Please indicate your availability for tutoring below:Monday 10am-2pm 2pm-5pm 5pm-8pm Tuesday 10am-2pm 2pm-5pm 5pm-8pm Wednesday 10am-2pm 2pm-5pm 5pm-8pm Thursday 10am-2pm 2pm-5pm 5pm-8pm Friday 10am-2pm 2pm-5pm Saturday 10am-1pm 1pm-4pm Sunday 11am-1pm 1pm-4pm How did you hear about North Avenue Education?*Google SearchYelp SearchFacebookFriend or ClassmateTeacher or College CounselorWalked ByWho referred you to North Avenue?* This iframe contains the logic required to handle Ajax powered Gravity Forms.