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Parent Intake Form

Home Resources Parent Forms Parent Intake Form

Student Information

Student Name *

Student Date of Birth *

Street Address *

City *

State *

ZIP *

Student Email Address *

Student Cell Phone Number *

Biological Gender *MaleFemale

Age *

Grade *

School *

Applicant lives with: *FatherMotherBoth ParentsOther

Check any that applyFather deceasedMother deceasedParents divorcedParents separatedFather remarriedMother remarried

Are you a U.S. citizen? *YesNoOther

In what sports and/or after school activities does the student participate? *

What community groups and/or organizations does the student belong to? *

1st Parent/Guardian Information

Name *

Address (if different from above)

City

State

ZIP

Phone *

Email *

Occupation *

College (if any)

Graduate School (if any)

2nd Parent/Guardian Information

Name

Street Address (if different than above)

City

State

ZIP

Phone

Email

Occupation

College (if any)

Graduate School (if any)

Sibling Information

Sibling Name

School

Birthdate

Graduation Year

Sibling Name

School

Birthdate

Graduation Year

Sibling Name

School

Birthdate

Graduation Year

Educational History

We also request that you please e-mail us a copy of the student’s transcript and standardized test scores.

Student Class Rank

Student GPA

Has the student taken the PSAT, ACT, or SAT? *YesNo

Please list the scores for each section.

Has the student ever repeated a grade? *YesNo

What grade was repeated and why?

Has the student ever been tested for a learning disability? *YesNo

When and by whom was the student tested?

Was the student classified by the school? *YesNo

When was the student classified?

What was the classification?

Is the student still classified?

Does the student have accommodations? *YesNo

What accommodations?

Study Skills

On average, how much time does the student devote to homework each weekday night

Do you have difficulty getting the student to complete homework? *YesNo

Please explain difficulties you experience.

Has the student ever been tutored? *YesNo

Which subjects and for how long?

Is the student currently being tutored? *YesNo

How is the student responding? Do you expect to continue the tutoring?

Please evaluate the student in each of the following areas (1=deficient to 10=exceptional)

Reading *12345678910

Study Skills *12345678910

Time Management *12345678910

Organization *12345678910

Writing/English *12345678910

Math *12345678910

Confidence *12345678910

Motivation *12345678910

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PO Box 456, Laurel, MT 59044

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