Sage Educators Student Registration

Have you already communicated with a Sage director via email or telephone? *

Yes, they have asked that I fill out this registration form.
No, this is my first communication with Sage Educators.

Which Sage services are you most interested in for your student at this time? *

Which tutoring schedule are you most interested in for your student at this time? *

Set Schedule
One Time Drop-in
As Needed
Other

Preferred Office: *

Mill Valley
Larkspur
Online

Student Contact Information

Student Name *

First

Last

Student School

Student Grade

Student Date of Birth

Student Email

Student Phone Number

Parent Contact Information

Parent Name *

First

Last

Parent Email *

Parent Phone (Primary) *

Parent Phone (Alternate)

How did you hear about Sage *

Single Line Text *

Student Education History / Goals

On which subjects or skills would you like us to focus during tutoring?

Please describe your current concerns (difficulty with specific subjects, lack of interest, disorganization, need more challenge, etc.)

Please provide the names of relevant classes and teachers.

Please provide login information for online grade/assignment access (if applicable).

Has your child been tested for learning disabilities? *

Yes
No

Please provide an explanation of your student's diagnosis.

Does your student have an IEP (Individualized Education Plan) or 504? *

Yes
No

Please provide an explanation of your student's accommodations.

Is there anyone (psychologists, counselors, etc.) with whom you would like us to be in contact?

Please describe any health conditions or medications of which we should be aware.

Is there anything else of which we should be aware?

Please describe your expectations and goals in working with Sage.

Consider if you're interested in grade improvement, general understanding, attitude, confidence, etc.

COVID-19 Release

Checkboxes *

I release Sage Educators, Inc. from any and all liability resulting from exposure to the COVID-19 virus.

Payment Information

Billing and Cancellation Policies *

Yes, I have read and agree to the billing and cancellation policies outlined below.

BILLING POLICY:

Clients will be billed during the first week of each month for all sessions of the prior month. We request that each client pay with a credit card. If a client chooses to pay by check, then we must have a back-up credit card on file and the check must be received within 10 days of the date of the invoice, or the back-up credit card will be charged. Please note that if a check is returned for any reason, the client will owe a $50 processing fee plus the amount of the check, which will be billed to the credit card we have on file.

CANCELLATION POLICY:

To show courtesy to our professional tutoring staff and accommodate the needs of all Sage students, we require a minimum of 48 hours’ advanced notice to cancel or reschedule a tutoring session, except in the case of illness.

Please note that appointments cancelled or rescheduled with less than 48 hours’ notice, as well as no-show appointments, will be charged in full.

Payment Method *

Cash
Check
Visa/Mastercard

Regardless of your preferred method of payment, we require that a backup credit card be kept on file.

Name on Card

Credit Card Number

Expiration Date

CVV

Sage Educators Foundation

Help Sage Educators Foundation provide educational opportunities for deserving students in need.

After checking this box, you will be redirected to PayPal to set up your donation.

Register for Tutoring

To sign up for tutoring, please tell us how we can best serve your student by filling out the intake form below.

Student Contact Information

Parent Contact Information

Student Education History / Goals

COVID-19 Release

Payment Information