Anderson Academy Tutorial Application
 

We are now accepting applications for students in grades 4-8 for the tutorial program.  Please complete the application below.  Please e-mail the completed application to drdajuane@andersonacademyms.com or fax to (954) 262-3988.

Name of student applying:______________________________________________

Last school attended:__________________________________________________

Current Grade____________________________

Gender:Male__ Female ___  Age:______Student Birth Date (mm/dd/yyyy)__________

Name of person filling out this form:______________________________________

Relationship to student:_________________________________________________

Tutorial Site Location: N. Miami Beach _____    Kendall _____ 

Parent/ Guardian Contact Information

Guardian #1 Name:____________________________________________________

Relationship to child:________________   Home Phone#:_____________________

Cell #:____________________________    Work #:_________________________

Occupation:_______________________    Employer:_________________________

E-mail address:_______________________________________

Guardian #2 Name:____________________________________________________

Relationship to child:________________   Home Phone#:_____________________

Cell #:____________________________    Work #:_________________________

Occupation:_______________________    Employer:_________________________

E-mail address:_______________________________________

Child’s Home address:__________________________________________________

City/State/Zip:_________________________________________________________

Emergency Contact Information

Additional Contact Name:_____________________________________________

Relationship to child:____________________________________________________

Cell #:________________________            Work#:__________________________

Additional Information

1.  How did you hear about the Anderson Academy Tutorial Program?________________

______________________________________________________________________

2.  Do you know any other student who might be interested in the program?_______

Student/Parent Name______________________Contact Number ________________

Signature of parent/guardian (required): ____________________________________

Date Submitted_________________________

Click here to download a PDF of the application.