Kinetic Minds Academy
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Consultation Request Form
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Preferred Program
*
Foundation Builder (1 session)
Momentum Package (4 sessions)
Mastery Accelerator (12 sessions)
Back-To-School Offer
Independent Study Program (Binder)
Evaluation Only
Specialized Sessions/Workshops
Professional Courses Assistance
Other / Not sure yet
If you didn’t find a good fit in the drop down menu options please choose ‘Other/Not sure yet” and specify what you are looking for in the section below “Learning Goals & Challenges”.
Looking forward to learning more about your journey!
Student Name
*
Parent/Guardian Name
Please leave your name here if you are filling out this form for your child. Thank you
Current Preferred Preferred
Email Address
*
Phone Number
*
Preferred language
English
Russian
Current Grade Level
*
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Higher Education/Professional
Other (please specify in Learning Goals)
Current Math Coursework
*
e.g., Fractions, Probability, Algebra II, Calculus, etc.
Optional Advanced Topics: Statistics, Economics, Business Finance,…
Learning Goals & Challenges
*
What specific areas would you like to focus on? What challenges are you currently facing?
Preferred Session Times
What days and times work best for you?
Your zipcode
This will help me understand where geographically you desire to receive tutoring services.
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