RITES Adult Tutoring Contract

Today's Date*

Referral Source*

Internet Search
Evaluator/Doctor
Friend
Social Media
Returning Family or Sibling
Other

Referred By

So we can thank the person, let us know who referred you.

Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Email*

College Name (only if attending College)

Optional: Briefly describe what skills you would like help with.

Demographics

African American
Asian
Pacific Islander
Hispanic
Native American
Multi-racial
Caucasian

Gender Identity

Male
Female
Other

Optional Release Form

If you would like us to connect with a teacher/school/doctor please check the box below giving us permission.

Consent

I give permission for RI Tutorial staff to connect with those listed below.

Please list name(s), email and/or phone for each contact.

Tutoring Contract

Fee Information*

I have read and agree to the fee structure information below.

INDIVIDUAL TUTORIALS:
$65 an hour
REGISTRATION:
$25 initial processing fees
$10 initial processing free summer only
TRAVEL FEES:
Minimum of $5 charged each session when a teacher travels to the student's house or school
OUTSTANDING BALANCES:
Must be paid in full within 30 days of the rendering of services.

Payment Options*

VENMO: Send payment to @ritestutoring and write your name in the message area.
CREDIT CARD: We take all major credit cards. A link will be emailed to you via our secure software to enter your information.
IF TUTORING OCCURS AT THE LEARNING CENTER ONLY: Cash or check (made out to RITES)

Venmo account name (if paying by Venmo)

Consent

General Consent*

I have read the information below. I understand and agree to these terms.

CONFIDENTIALITY:
All records, reports, and personal information shared with RITES will be kept confidential.
CANCELLATIONS:
The individual services provided by RITES do not permit us to overbook appointments. When an appointment is confirmed, we commit ourselves to incur other expenses for the time spent with you. Unless cancellations are made at least 24 hours in advance, and except for any unavoidable emergency, you will be charged the full fee for missed appointments.
TERMINATION:
RITES reserves the right to terminate all future tutorials if, at the sole discretion of RITES, the student is unable or unwilling to be tutored in a satisfactory manner, failure to pay, or upon breach of any term of this contract.

Publicity Consent*

I have read the information below. I understand and agree to these terms.

PUBLICITY:
We occasionally publicize our work for the purpose of applying for grants, fundraising, reporting to our Board, and advertising and marketing our services, and seek permission from you to take photographs, video and/or ask for a testimonial or for information to create a "success story." We will give you notice ahead of time whenever the need to collect these materials is necessary, so that we can coordinate the effort with you. You have the opportunity to indicate if you prefer to have your name withheld, no images only, no publicity at all, etc. below.

Publicity Consent Options (Check all that apply)*

May use my name
May use my image
May use a quote from me
None of the above

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Tutoring Contract: Adult

Contact Information

Optional Release Form

Tutoring Contract

Consent

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