Student Coaching Application

Student Coaching Application

Please complete this application in full. Providing accurate information and signing the acknowledgement and consent sections are required for processing. Submission of this application does not constitute a guaranteed placement; acceptance will be confirmed in writing by the coaching provider.

Applicant Information

Date of Birth:    Student ID:

Grade / Year:    Current GPA (if applicable):

Parent / Guardian Information (if applicant is under 18)

Is applicant under 18? Yes

Coaching Program Details

Requested Areas (check all that apply):

Math & Quantitative Reasoning    Writing & Composition    Science   

Test Preparation    Study / Executive Functioning    College Application / Essay Coaching

Preferred service format: In-person Virtual Hybrid

Desired Start Date:    Typical Session Length:    Frequency:

Educational Background & Goals

Does the student have an IEP or 504 plan? Yes No

Emergency Contact & Medical Information

Relationship:    Phone:

In the event of a medical emergency, I authorize the coaching provider or its representatives to seek emergency medical treatment on behalf of the student as deemed necessary. I understand I will be notified as soon as practicable.
I authorize emergency medical treatment as described above.

Policies, Fees & Consent

Fees: Client agrees to pay coaching fees as quoted at intake. Fees for individual sessions, packages, or group services are due in accordance with the invoice. Late payments may incur interest at a rate not to exceed 1.5% per month and may result in suspension of services until paid.

Cancellation and No-Show: Cancellations must be made at least 24 hours in advance. Sessions cancelled with less than 24 hours' notice or failure to attend will be charged the full session fee unless otherwise excused in writing by the provider. Repeated cancellations may result in termination of services.

Confidentiality and Records: Records maintained by the coaching provider are confidential, but the provider may disclose information as required by law (including mandatory reporting), or to other education professionals with prior written consent. By signing this application, Client authorizes release of school records necessary to provide effective coaching.

Limits of Service: Coaching is educational support and does not substitute for clinical, medical, or psychiatric treatment. The provider makes no guarantees regarding specific academic outcomes or admission results.

Liability and Indemnification: To the fullest extent permitted by law, Client releases and agrees to indemnify the provider and its employees from any claims, liabilities, or expenses arising from participation in coaching services, except where caused by the provider's gross negligence or willful misconduct.

Acknowledgement:
I acknowledge that I have read, understand, and accept the policies, fees, release, and limits described above.

Authorization to Obtain Records & Media Release

Authorization to Obtain Records: I authorize the release of academic records, testing reports, and related educational information from the school and other educational service providers to the coaching provider for the purpose of assessment and development of a coaching plan. This authorization remains in effect for the duration of coaching services unless revoked in writing.

Media Release (optional): I grant the provider permission to use non-identifying photographs or testimonials for general informational or promotional purposes. I understand I may decline without affecting services.
I consent to non-identifying media use.

References / Prior Services

Certification and Signature

By signing below, I certify that the information provided in this application is true and complete to the best of my knowledge. I authorize the coaching provider to obtain necessary educational records and to communicate with school personnel, previous tutors, or other professionals as needed to support coaching. I accept financial responsibility for coaching services and agree to the policies stated above.

If the applicant is a minor, the parent or legal guardian signing below represents that they have the legal authority to consent to these terms on behalf of the student.
I certify and consent as described above.

Sign Now