Student Information Student Name *
Expected Incoming Grade Level * Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Adult Student Gender * Male Female Student's Mobile Phone Number * Student's Email Address *
Student Lives With (check all that apply) * Parent/Guardian Information Main Contact Email * Father's Name *
Father's Mobile Phone Number * Mother's Name *
Mother's Mobile Phone Number * Emergency Contact Emergency Contact *
Person other than parent/legal guardian who is to be contacted in case of emergency. This person must be local and from a separate household.
Relationship * Phone * Desired Start Date *
MM slash DD slash YYYY
If your student is a K12 student, do you currently receive or do you plan on applying for a Gardiner scholarship award to help pay for your tutoring? Please check all that apply * Payment agreement in advance, monthly *
We agree to pay $55/hour to Wellmont Academy for our child’s Barton tuition, monthly, on the first of each month, through FACTS. We understand that there is an annual fee of $50 payable to FACTS in order to use this service if our family is not already using the service for our regular Wellmont Academy tuition payments. We understand that tutoring will cease if not paid for by the 3rd unpaid session of the month. We also understand that at any time, for any reason, Wellmont Academy may choose to terminate our student’s enrollment in Barton tutoring, making all payments and fees non-refundable if they see fit.
We understand and agree. We do NOT agree. Agreement to standing appointments *
We agree that regular attendance is critical to achieving growth. We understand that make-up sessions will be offered for missed appointments by our tutor when 24 hours notice is given for sickness or a missed session. Make-up sessions will be offered according to the availability of the tutor. Missed sessions will not be refunded unless the tutor cancels and cannot offer a makeup session. Excessive cancellations without makeup sessions may result in the termination of services for your student.
We understand and agree. We do not understand. We do NOT agree. Family Attendance Agreement *
Wellmont Academy no longer allows family members of students inside the school building without a standing appointment. If you wish to come inside to speak with your tutor, please request an appointment with them.
We understand and agree. We do NOT agree. Summer Attendance Agreement *
Barton tutoring is based on the consistent repetition of material, so summer attendance is also a necessity. Wellmont Academy will provide a minimum of 6 weeks of summer tutoring, which is necessary to your child’s retention of the material. Scheduling can be worked out with your tutor to maximize summer memory retention and allow for vacations.
We understand and agree. We do NOT agree. Photo Agreement *
I agree that my student’s photo may be posted on the Wellmont Academy Facebook and Instagram sites for the purpose of celebrating accomplishment or promoting Barton services. I understand that their name and age will NOT be posted.
We understand and agree. We do NOT agree. Testing and other services *
We understand that Wellmont Academy Barton tutors do not complete psychological evaluation diagnostic tests, nor do they participate in advocacy work. They do not attend IEP or 504 meetings.
We understand and agree. We do NOT agree. Discontinuing Services *
Barton Services may only be discontinued per quarter. Wellmont Academy must receive a notice to discontinue in writing 2 weeks prior to the end of the quarter to avoid the next quarter’s fees.
We understand and agree. We do not understand. We do NOT agree. Notice of Rights
Wellmont Academy of Tampa Bay, Inc. admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of it’s educational policies, admissions policies, scholarship and load programs and athletic and other school-administered programs.
Application Fee *
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