Student Information
Student Contact Information
First Name* 
Last Name* 
Mobile Phone  
Email Address 
Date Of Birth* 
Home Address* 
Country of Residence* 
Passport Number
Parent Information
Parent Contact Information
First Name*
Last Name*
Mobile Phone*
Email Address* 
Home Address 
Country of Residence  
Passport Number
Grade of Student (Last Grade Completed)* 
Additional Notes 
Has student ever received Special Education Needs Services? 

If yes, please provide details and upload IEP or SEN documents

Academic Skill Level

I am an ESL Student. (English is not my first language)

 Are you interested in enrolling in one of our Success Center programs?

Please upload transcript. *


I understand that the Learning Coach (LC) is the adult in the home who will assist the student with completing their daily tasks. The amount of assistance depends on the student's grade level and the student's ability to complete work independently.

Elementary School (K-5)

A lot of monitoring is required for students in Grades K-5. The Elementary School Learning Coach will be actively involved with the student spending an average of 3-6 hours each day. During a typical week, the Learning Coach will:

·         Assist with lessons

·         Monitor comprehension

·         Modify daily schedule

·         Log attendance

·         Communicate with teacher

Middle School (6-8)

The type of assistance provided by the Middle School Learning Coach varies, based on the student's independence. The Learning Coach will spend an average of 2-4 hours a day. During a typical week, the Learning Coach will:

·         Assist with some lessons

·         Monitor comprehension

·         Encourage independent learning

·         Log attendance

·         Communicate with teachers

High School (9-12)

The High School Learning Coach may spend less time assisting their student based on the student's ability to work independently. The average amount of time spent by the Learning Coach with a High School student is 1-2 hours a day. During a typical week, the Learning Coach will:

·         Assist with some lessons, varies based on student's independence

·         Verifies lesson completion to ensure student is on track

·         Supports student independence

·         Attends teacher conferences