Grove Academic Performance Institute: Bridge the GAP

Parent or Guardian Information

Parent Name *

First

Last

Parent Email - IMPORTANT: Invoices will come to this address. *

Parent Phone Number - IMPORTANT: Must be different than student cell phone number. *

Parent Address *

Address Line 1

Address Line 2

City

State

Zip Code

Add Another Parent? *

Yes
No

Parent Name

First

Last

Parent Email

Parent Phone Number

Parent Address

Same as Above

Parent Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Emergency Contact Relation to Student *

Student Information

Student Name *

First

Last

What does your student like to be called?

A nickname or preferred name, if it's different from their first name.

Student Gender (copy) *

Student Email *

Student Doesn't Have Email

Student does not have a personal email.

Student Phone Number *

Student Doesn't Have Cell Phone

Student does not have a personal cell phone.

Student Birthday *

Graduation Year *

Current School *

Current Grade Level *

Program Interest

What days are you generally available? Select all that apply. *

Monday
Tuesday
Wednesday
Thursday

Select all areas of interest.

Coaching/Tutoring

Math
Science
Language Arts
Reading/Writing

Standardized Test Prep

ACT Prep
SAT Prep
PSAT Prep

Has your student taken the ACT, PreACT, SAT, or PSAT?

Yes
No
Not Sure

If so, when did they test — and what were the section and composite scores?

If they haven't tested yet, when are they planning to?

Any colleges, scholarships, or long-term goals they're working toward?

Executive Functioning

Study Skills/Organization

Summer 1-1 Tutoring

Test Prep
Math
Reading
Other

Please Explain

Student's Current Math Level

Please Explain

Select all the subjects you are interested in for the ACT and/or SAT.

Math
Science
English
Reading

If you have completed a standard test please upload your test results.

Click or drag files to this area to upload. You can upload up to 5 files.

How did you hear about our services? *

Please provide referral specifics. (School Name, Individual Name, Website, etc.)