Student Registration Form for Academic Support Services

Student Registration Form

All information collected here will be used for correspondence with UP and shared directly with your specialist, so we request that you fill out each question carefully and accurately. A copy of the policies and procedures below will be emailed to you for your records. We appreciate your time and care, and we look forward to serving you!

How did you hear about us?

How did you hear about Unlocking Potential?*

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Please share - How did you hear about us?*

Please list the name(s) of the organization or individual that referred you.

Basic Information

Parent/Guardian Name*

First & Last Name

Student First Name*

Student Last Name*

School Name*

Student Grade*

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Other, - Please Explain*

Mailing Address*

City*

State*

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Zip Code*

Preferred Email Addresses*

Please list all email addresses you would like copied on your student's updates and UP communications. Please use a comma to list multiple email addresses.

Preferred Phone No.*

What subjects are you looking for support with?*

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Are there any other subjects or skills you would like support with?*

My Specialist

My Ideal Specialist:*

Please select what is most important to you in a specialist.

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My Ideal Specialist:*

What is the second most important thing to you in a specialsit?

Select

My Ideal Specialist:*

What is the third most important thing to you in a specialist?

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Are there additional qualities that you would you like your specialist to have?

Accomodations

Does your student have any accommodations due to diagnosed learning differences?*

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What accommodations does your student have?*

Please list all accommodations, e.g. extended time, private room, format modifications, etc.

File Upload - Accommodation Documents

If you would like to share any documents pertaining to your students accommodations or learning differences please do so here. This is not required and if you believe it may be helpful to your student's specialist, we will be sure to share it with the specialist.

Drag and drop files here or

Scheduling & Logistics

On a regular basis I have the following scheduling conflicts:*

Additional Information*

Do you have any questions, feedback, or concerns about the preparation process or your student? Or is there anything else that you would like to share?

Student Google Account Information:*

We use Google Drive to share our online workbooks. We ask that students create a Google account if they do not already have one. We will not use this information to communicate with the student, only to share the curriculum materials. Please list the email address associated/linked with your Google account.

Parent Google Account Information:*

Please list the email address associated/linked with your Google account.

Unlocking Potential Policies & Procedures

Unlocking Potential Procedures*

Once registration/payment has been completed, your specialist will contact you to schedule the first session. All scheduling will be done directly with the specialist. After the initial session, UP will contact you to ensure complete satisfaction. You can also feel free to reach out immediately if there are any questions or issues. Specialists keep session notes and track hours in a document shared with UP. If you have questions about hours or content of sessions, we are happy to share this information. If you are approaching the end of your package hours, UP will be in contact to check in about purchasing additional hours. You can always go online to purchase more hours at your convenience. Direct all questions about registration or payment to UP, not the specialist. Please keep us informed about academic successes! We love to hear your results! By checking the box below I acknowledge that I have read the Unlocking Potential Procedures and agree to follow said procedures.

Unlocking Potential Policies*

Packages are non-refundable once purchased. If for any reason there are additional hours left at the end of a season, hours can be applied toward ongoing academic support, another student, or any other purpose that suits the family’s educational needs. Registration/payment must be completed before scheduling a session. We ask that you do not solicit UP specialists for any outside services. If you have a question about an additional service and would like to request your specialist, please contact UP directly. UP claims no legal responsibility for any injury or other event that occurs during a session. Specialists are expected to be prompt and keep re-schedules to a minimum to honor your schedule. We ask that you do the same to honor the specialist’s schedule. If you have an issue with a specialist being late or rescheduling, contact UP so that this can be addressed immediately. If you cancel a session within 24 hours of the session, half of the session time will be deducted from your package. If you cancel a session within 2 hours of start time, the full session time will be deducted from your package. These cancellation policies apply whether the session is cancelled by a parent/family member or a student. We ask that you keep your conversations with your specialist within the designated session time and that you keep text or email communications to a minimum. Any additional questions can be directed to UP via email or phone. If ANY issues arise with the specialist or customer experience at any point along the way, be in contact with UP immediately. Your complete satisfaction is very important to us, and we are happy to help navigate any concerns or challenges. By checking the box below I acknowledge that I have read the Unlocking Potential Policies and agree to follow said policies.

Send me a copy of my responses

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