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To Request Information: Please complete the form below.

     Parent/Guardian Name: 

    Address: 

                    

    City:   ,  State:         

    Zip:    

    Home Phone: -     

    Work Phone:  -

    Email:  

    Student Name:

          Age:      Gender: Male    Female     Grade:

    School:

    Please select the subject areas the Student requires tutoring:

    Elementary:     Math    Reading Writing       

                                Special Education Other

   Middle School:   Basic Math    Math     Pre-Algebra Algebra               

                                English   Science  Social Studies    

                                Special Education Other

    High School:    

                            Math: Algebra I Algebra II Calculus Geometry

                                       Pre-Calculus Trigonometry   

                                       Other

                        English: English Composition   Reading Comprehension

                                       Other  

                       Science: Earth Science   Biology   Chemistry Physics 

                                       Other

            Social Studies: World History/World Cultures   US History I   US History II  

                                        Other

          World Language: French I  Spanish I Italian I

                                         French II  Spanish II Italian II

                                         French III  Spanish III Italian III

                                         Other

     Test Prep: HSPA English SAT English HSPA Math SAT Math

                        GED    State Achievement Tests

                        Other

    Other: English as a Second Language (ESL)

                Computer Training

                Guidance Counselor Services

                Other

    How did you hear about Mega Smartz:

                    If Other, Please specify

   Would you be interested in Online tutoring experience     NO    YES                   

İMega Smartz, reserve all rights. Date modified: July, 2010