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©2019-2020 by Sammy's Math and Chemistry Online Tutoring LLC

Registration Form:

 

Please fill out all fields below and submit form. However,

if you are in Nevada, California, Texas, New York, Oregon and Washington, please contact me at 321-345-6894 before you fill out the form.

Thanks!

Student's First and Last Name

Student's Street Address

Student's City

Student's State or Province

Student's Zip Code

Student's Email Address

What concepts are you having problems with?

What is/are your current grade(s) in your course(s)?

Student's Cell Phone Number

Student's Birthday MM-DD-YYYY

Is student over or under the age of 18 years? Enter yes for over 18 or no for under 18 below.

If student is under the age of 18 years then please fill out the required fields below. Also, If you are over 18, please fill out the 3 fields below.

Parent's (or Student's) First and Last Name

Parent's (or Student's) Email Address

Parent's (or Student's) Cell Phone Number

What course or courses do you need help with?

What are the goals you are expecting to get out of tutoring?

What times (morning, afternoon, and/or evening) of day are you available for tutoring? Please state all times below.

What days (Monday through Sunday) are you available for tutoring? Please state all days below.

How did you hear about my company?

I have read and agree to the Terms of Service and Privacy Policy of this website as well as the website’s use of cookies.