2025-2026 TUTORING ENROLLMENT

Tutoring takes place at Little Flower.

We have openings on Wednesday and Thursday at Little Flower.

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Child's School and Grade

Race (Please check all that apply)

Black

Hispanic

Multiracial

White

Other

Child's Gender

Does your child have any allergies ?

Please list any allergies if yes.

Parent or Guardian's Name

First Name

Last Name

Relationship to the student

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email:

Phone Number

(###)

###

####

Primary Teacher's Name

First Name

Last Name

Teacher's Email

Teacher's Number

(###)

###

####

I give permission to Lolly's Place administration and tutors to communicate directly with my child's teachers.

Please provide an electronic signature

Emergency Contact #1

First Name

Last Name

Relationship to the student

Permission to pick up child?

Phone Number

(###)

###

####

Emergency Contact #2

First Name

Last Name

Relationship to the student

Permission to pick up child?

Phone Number

(###)

###

####

Areas of Tutoring Focus

Math

Reading

Study Skills + Time Management

Tutoring Payment Policy - Please read and provide an eletronic signature:

Tutoring payments are due the 15th of the month. The cost is $220 per month. Disregard if your child is on scholarship.