chappaqualearningcenter.com
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Student Application Form
Student Information
Student's First Name
Student's Last Name
Student's Cell Phone (if applicable)
Student's E-Mail Address (if applicable)
Current High School
GPA
Please Select Which Topics Your Child is Interested in.
SAT Critical Reading
SAT Math
SAT Writing
ACT English & Reading
ACT Math & Science
Biology
AP Biology
Chemistry
AP Chemistry
American History
AP American History
Global History
AP Global History
Grade School Math (1–12)
English
Writing
Previous PSAT Scores
CR:
Math:
Writing:
Previous SAT Scores
Date Taken:
CR:
Math:
Writing:
Previous SAT II Scores
Subject:
Score:
Subject:
Score:
Previous ACT Scores
Date:
English:
Math:
Reading:
Science:
Date:
English:
Math:
Reading:
Science:
Previous Tutoring:
Parent/Guardian Information
Parent's First Name
Parent's Last Name
Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-Mail Address
Additional Comments
(ie: student is eligible to take exams with extended time):
Health Information
Candy is available during tutoring sessions. Does
your child have any food allergies, or any other
physiological conditions that might present themselves
during a tutoring session (peanut allergy,
diabetes, hypo or hyperglycemia, epilepsy, etc?):
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