Tutoring registration

Part 1: Student particulars (Please use BLOCK letters)

Student's Full Name

DOB

Gender(required)

School

Year Level

Exam Pathway

If other then please specify :

Parent's Name(required)

Postal Address(required)

Family email address(required)

Work email address

Parent's Mobile number(required)

Student's Mobile number

Home number

Part 2 : Any learning Preferences/Diagnosis

If box ticked please add extra information

Part 3 : Any other areas of concern

Attention/FocusFollowing InstructionsLanguageOrganizational difficultiesHandwriting/fine motor difficultiesNoneOther

If box ticked please add extra information

Part 4 : Any Health/Medical issues ?

Eyesight : glasses Y/NHearing APD/Hearing aidsCo-ordinationMedicalNoneOther

If box ticked please add extra information

Part 5 : Previous Assistance at School

RTLBRTLiTWriting group-schoolPeer tutoring-schoolGifted and Talented groupMathematics supportPrivate TutoringReader/WriterNumber worksKip McGrathPrivate TutoringESOLReading supportKumonSPELDSocial skills groupUse of Laptop/Netbook etcSpeech TherapyOccupational therapyPhysiothearpyOther

Other information you would like to add

Part 6 : Information Particulars

How did you hear about us ?(required)

Friend/Work colleagueSchool recommendationBrochureInternet searchOther

If you would like to receive Kidz Newz (1 x a term email)

Please read the Terms and Conditions carefully.

I have read and agree to the Terms and Conditions. Please ask for clarification of any points you are unsure of. This document is issued on 19/01/13 and supersedes any previous terms and conditions issued by KTL Tuition formerly known as Kidz Therapy Ltd.