RTS Success® Registration

Please complete the application below.

We will contact you within 2 business days to discuss the next steps!

Please note that (*) indicates a required field

Name*

First Last

Gender*

Male
Female
Other

Age*

Date of Birth*

How did you hear about us?*

Reason(s) for seeking services (please check all that apply):*

If other, please explain*

Present Grade*

Last Grade Attended*

Last Recorded G.P.A.*

Last Degree Received

School*

Home Address*

Street Address City State ZIP Code

Parent(s) name or responsible paying party:*

Student Email*

Student Contact Phone*

Student Contact Phone Type*

Home
Mobile

Parent/Guardian Email 1:*

Parent/Guardian Cell 1:*

Parent/Guardian Email 2:

Parent/Guardian Cell 2:

Does student enjoy reading?*

Yes
No

Does the student prefer to be:*

read to
reading independently?

Handedness*

Right
Left

Does the student have any previously diagnosed learning issues?*

Yes
No

If "Yes," please specify below and email documentation to Cindy@RTSsuccess.com*

Have you received prior tutoring services?*

Yes
No

Please describe your previous tutoring services.*

We request that the student complete the following part of this application

Do you (student) like to read*

when it is quiet?
when there is some noise?

What do you like to read the most*

Books
Magazines
Computer

How difficult are the following:*

	Easy	Somewhat Difficult	Difficult	N/A
To pronounce new words while reading?
To comprehend when reading for leisure?
To comprehend school reading material?
To remember written telephone numbers?
To remember verbal multi-step directions?
To recall information for tests?
To recall information several weeks after the test?
To remember people’s names or jokes?
To remember the lyrics in a song?
To hear people talking clearly from another room?
To read for pleasure for more than 30 minutes?
To express myself through writing?
To express myself through speaking?
To study for a test?
To study for finals (if applicable)?
To retain previously learned information months after the test?

Please choose the best answer:*

	No	Sometimes	Yes
When I look at words, do I mix up letters like “b” and “d”?
While reading, do I place my fingers under the words?
Do I often mix up words that look alike?
If I stop to sound out a new word, do I often forget what I am reading?
Do I ever lose my place on the page while I am reading?
Do I know the “rules” when I sound out new words (i.e. two vowels together are a long vowel sound?
Do I think of myself as a good speller?
When I learn the definition of a new word, can I remember it easily for later use (6-months later)?
Do I use my hands a lot when I talk?
Do I picture or imagine things in my head while reading?
While watching television, and a person near me is asking me a question, can I clearly hear that person?
Do I find myself rereading information?

Check all favorite subjects*

Math
Science
English
Social Studies
Music
Art
Other

If other, please explain*

Please list all weekday and weekend availability:*

Comments

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