New Client Intake Form

Student Information

First
Middle
Last

Month
Date
Year
Age

Grade

Mother's Information

First Name
Last Name

City
State
Zip



Cell
CallEmailText

Father's Information

First Name
Last Name

City
State
Zip



Cell
CallEmailText

School Name and Address

Name
Address
City
State
Zip
NY Public SchoolPrivate
Siblings Names


Grade


Referred by

Emergency Contact

Name
Home Phone
Work
Cell
Child Lives With
Name
Relationship
Your Name
Your Signature
Date

KINDLY SIGN AND DATE AT THE BOTTOM.

To Our Clients:
This is to inform you of our cancellation and lateness policy.

Cancellation:
A reasonable cancellation made in advance (usually 24 hours) will be honored without a charge to the client.

A cancellation made on the same day of the appointment within 3 hours of the scheduled appointment will result in the client paying for the full session.

Lateness:
The time will be deducted from the child’s session for lateness up to 10 minutes and the full payment for the session will be expected.

With any lateness over 10 minutes, we will have no choice but to cancel the session and full payment
of the session will be expected.

We hope you find this policy reasonable. We have many children that visit us and we truly appreciate that everyone makes and effort to respect our schedule.

Please understand that our first priority is the education of your child and we can only reach our goals by working together. Thank you.

Maria Casale
Leap Tutoring Academy

SIGNATURE OF PARENT/GUARDIAN:
DATE

I agree that I have read and understand the terms outlined above.