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Future Leaders Childcare & Tutoring Services
TUTORING AND AFTER SCHOOL ACTIVITIES APPLICATION
Student's First Name
*
Student's Last Name
*
Birthday
*
Month
Day
Year
Parent's Name
*
Email
*
Phone
*
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Emergency Contact (Name and Phone Number)
*
What subject does your student need help in?
*
Math
Reading
Other
Does your student need transportation from school to our location?
*
Yes, my student needs to be picked up
No, I will drop off my student
Student's School
*
School Address
*
Does your student have any allergies?
*
Comment
By signing below, I agree to enroll my child in the Future Leaders after-school tutoring program at a weekly fee of $85.
*
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