Student Information Student Name *
First Last 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 DOB *
MM slash DD slash YYYY Student's Mobile Phone Number * Student's Email Address *
Parent Statement for Enrollment *
Please give a brief but comprehensive statement your are applying to Wellmont Academy for Barton tutoring for your child.
Address Information Current Address * Student Lives With (check all that apply) * Family Members (check all that apply) * Parent/Guardian Information Main Contact Email * Father's Name *
First Last Father's Mobile Phone Number * Father's Email *
Mother's Name *
First Last Mother's Mobile Phone Number * Mother's Email *
How did you hear about Wellmont's tutoring program? * Friend Relative Website Search Pinellas Parent Educators Association Facebook Instagram Emergency Contacts 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.
First Last Relationship * Phone * Medical Information Please list any medical concerns or psychiatric care we should be aware of. If none, please type "N/A". * Desired Start Date *
MM slash DD slash YYYY Has student previously attended Wellmont Academy? * yes no Do other siblings attend Wellmont Academy at this time? If so, please list their names and grades. *
If none, type N/A.
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 * Agreement to abide by the rules of Wellmont Academy *
As parents and prospective tutoring students, we agree to abide by the rules of Wellmont Academy.
We understand and agree. We do NOT agree. 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 consistency in attendance is critical to achieving growth. We agree 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 *
Siblings of the tutoring student are not allowed to attend sessions, nor are siblings to be left without a parent on campus. Parents and siblings may wait together in the Administrative Office for sessions to be completed if the office is open. Students are not to be dropped off early or picked up late from sessions, as we cannot be responsible for the supervision of your child outside of their appointment time.
Please notify our office if there are changes regarding the person picking up your student.
We understand and agree. We do NOT agree. Summer Attendance Agreement *
We agree that because Barton tutoring is based on the consistent repetition of material, summer attendance is also a necessity. Wellmont Academy will provide at least 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’s Barton tutors do not complete diagnostic tests, nor do they participate in advocacy work, or attend IEP or 504 meetings. They do not consult with or contact a student’s teachers or other extended relatives except by special arrangement and for an agreed upon fee.
We understand and agree. We do NOT agree. Discontinuing Services *
If you wish to discontinue Barton Services, two weeks written notice is required.
We understand and agree. We do not understand. We do NOT agree. Evaluation Included
This application includes a free Barton evaluation to determine Barton placement.
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 *
Price: Credit Card * Email
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