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Grades 3 to 8
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Student Application
Student Application
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Indicates required field
Parent/Guardian Name
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First
Last
Parent or guardian name.
Main Phone Number
*
Please enter the best number to contact you.
Secondary Phone Number
*
Parent Email
*
Parent email address.
Student Name
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First
Last
Name of the student who will be enrolled.
Student Gender
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Male
Female
Prefer not to say
Please check a box.
Student Grade
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Enter the student grade level.
Name of Current School
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Please enter the school that the student currently attends.
Student Email
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Please enter in the students email address.
Home Address
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Line 1
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City
State
Zip Code
Country
Please enter in your address.
Does the student have an IEP (Individualized Education Plan), ADD, ADHD, severe allergies, or receive any special service?
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Yes
No
Other (please specify below)
Choose from the list below, if you choose 'other' please specify in the box below.
If Other please specify:
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If you chose other, please give details in the box below.
Which class/subject would you like to enroll in?
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Choose type of prep.
Please choose which days are preferred for tutoring.
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Choose which days and time work best for tutoring.
How often would you like tutoring?
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Please choose how often you would like tutoring.
When would you like tutoring to begin?
*
Please specify a start date for tutoring.
Please enter in your credit card information below to be able to reserve upcoming classes and tutoring sessions. Credit cards are used as a hold, but do not need to be used for payment.
Credit Card #
*
Expiration Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Year
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Please enter the year this card expires.
Security Code
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Zip Code
*
Please enter the zip code associated with this credit card.
Emergency Contact
Name
*
First
Last
Relationship to Student
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Please indicate how this person is related to the student.
Address
*
Line 1
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City
State
Zip Code
Country
Phone Number
*
Secondary Phone Number
*
Terms of Service
Please read and review our Terms of Service below.
All students must be picked up on time. Gold Key Academics is not responsible for students dropped off early or left unattended after dismissal. Gold Key Academics reserves the right to release a student for inappropriate behavior (without a refund). Gold Key Academics reserves the right to cancel sessions/classes due to inclement weather, teacher illness, or unforeseen events. If Gold Key Academics cancels a session/class, a makeup session/class will be scheduled. Parent, guardian, and student agree to release Gold Key Academics and its representatives from liability in the event of an accident or injury while on the premises of 303 Bradley Ave Staten Island, NY 10314 and as well as professional liability if a student does not perform up to expectations. We are not obligated to provide refunds of any kind for services rendered. Late payments are subject to a $35 initial fee. By agreeing with 'Terms of Service': Gold Key Academics is granted permission to charge the credit card on file for any missed payments or balances due for services rendered.
Parent/guardian will be charged a $35 fee for any missed or canceled tutoring session without 24 hours notice.
Enter Full Name for Terms of Service Acknowledgment
*
Please enter your full name in the box to aknowledge you understand the 'Terms & Conditions' stated above.
Additional Information
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Please enter any additional information.
How did you guys hear about us?
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Please specify how you guys heard about our tutoring services.
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