Application Student First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Date of Birth Place of Birth Child Resides With Both Parents Mother Father Other School Applicant Now Attends Grade School Counselor School Counselor Phone (###) ### #### Mother First Name Last Name Phone (###) ### #### Present Address Email Occupation Employer Name & Address Work Phone (###) ### #### Father First Name Last Name Phone (###) ### #### Present Address Email Occupation Employer Name & Address Work Phone (###) ### #### Who has financial responsibility for the student? Email Invoices will be sent electronically. Please, provide a reliable email for that purpose. Sibling Information Name, Grade, School How did you hear about Complete Education? Counselor Exterior Office Sign Tutor list Internet Friend Have you been tested for a learning disability? Yes No Not sure What classes would you like to take with Complete Education? 54 sessions 32 sessions 24 sessions 16 sessions # sessions Have you taken any of these classes before? Yes No Explain If yes, what was (were) your grade(s)? What goals do you have for the class(es)? When would you like to start? MM DD YYYY Thank you!