A ccelerated A cademic A chievement A cademy

1. A A A A AcceleratedAcademic AchievementAcademy 9903 Brockington Road, Suite 108 Sherwood, AR 72120 501-834-0307 Hours of Tutorial Availability: (By Appointment Only) 6:00-9:00 p.m.(Mon.-Thurs.) 10:00 a.m.-5:00 p.m. (Sat.) T “Academic Fitness Is Our Business”

2. Student Information Date:_______________________________________ Student’s Name:_____________________ Age:____ Birth date:___________ Grade:_______ Address: __________________________ City:_________________________ Zip_________ Home Phone: _________________________ Cell Phone:_____________________________ Father’s Name:________________________ Mother’s Name:__________________________ Occupation: __________________________ Occupation: ____________________________ Employer: ____________________________ Employer: _____________________________ Work Phone: ___________________ Ext:___ Work Phone: ___________________ Ext:____ Number of siblings:_____________________ Siblings’ Ages: __________________________ How did you hear about Accelerated Academic Achievement Academy? ___________________________________________________________________________ ================================================================== Medical History: Yes No (If the answer is yes, please explain) 1. Does the student wear glasses? ___________ ________________________________ 2. Any hearing or speech problems? ___________ ________________________________ 3. Any serious early childhood health problems? ___________ ________________________________ 4. Any current health problems? ___________ ________________________________ 5. Currently on medication? ___________ ________________________________ Yes No (Describe reading or math problem, if applicable) Has student ever had a psychological or neurological evaluation? __________ _______________________________ When? ______________________________________________________________________________ By whom? ___________________________________________________________________________ Yes No Is student currently in any special placement in school (reading, math, speech, EH, LD? __________ ________________________________ ____________________________________________________________________________________ ================================================================== School: ___________________________________ District: __________________________________ Teacher: __________________________________ Principal: ________________________________ Parent/Guardian Signature: _____________________________________________________________

3. Parental Expectations and Commitment • Describe the academic strengths of your child. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Please circle your child’s current level of performance. (a) at grade level (b) above grade level (c) below grade level • Please check areas of academic needs. My child needs academic mentoring in the following: (a) Writing (b) Oral reading and word recognition (c) General math (d) Advanced math (algebra, geometry, calculus, trigonometry) (e) Literacy (f) General science (g) Advanced science (biology, chemistry, physics) (h) Social studies (i) Study skills (k) Homework assistance (l) Preschool readiness skills (m) College planning (n) College applications (o) Listening, public Speaking (p) Vocabulary development • Describe your academic expectations for your child. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Parental Expectations and Commitment 5.Please circle areas of academic strengths. My child’s strengths are the following: (a) Writing (b) Oral reading and word recognition (c) General math (d) Advanced math (algebra, geometry, calculus, trigonometry) (e) Literacy (f) General science (g) Advanced science (biology, chemistry, physics) (h) Social studies (i) Study skills (k) Homework assistance (l) Preschool readiness skills (m) College planning (n) College applications (o) Listening, public speaking (p) Vocabulary development (q) Organization (r) Note taking • Has any of the following been identified as a problem for your child?: (a) Chronic illness (b) Attendance (c) Discipline (d) Test anxiety (e) Poor attention span (f) Social skills (g) Coping skills (h) Emotional development (i) Peer relationships

5. Parental Expectations and Commitment • Has your child ever been retained? Or recommended for a comprehensive evaluation? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ • What prompted you to seek academic tutorial assistance? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ • What are your expectation about your child’s performance after the first 18 tutorial sessions? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ • Please describe any other relevant information that may help us better serve the needs of your child. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ For Official Use Only Target ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Diagnostic Assessments Results ________________________________________________________

6. Arrival/Departure Policy • I understand that the Accelerated Academic Achievement Academy personnel cannot assume responsibility for students who arrive early and do not enter the Academy or for students who leave after instruction when no one is waiting on them. I understand that it is my responsibility to accompany my child to and from the Academy. I will accompany my child to the Academy, wait with him/her until instruction begins and will be available to meet my child as the instructional session ends. • I acknowledge that I am informed of this policy, will adhere to it, and will accept full responsibility for my child until his/her instructional session begins and when it ends. • Acknowledged by: __________________________________________ • Parents Name: ___________________________________________ • Student’s Name: ___________________________________________ • Date: ___________________________________________ • -------------------------------------------------------------------------------------- • EMERGENCY RELEASE FORM • In the unlikely event of an emergency where I (or my spouse) cannot be contacted, I authorize the Accelerated Academic Achievement Academy staff to secure whatever medical care is necessary for the safety and well being of my child. I will assume all costs incurred for emergency care. • In Case of Emergency Contact: Name & Phone #: • __________________________________________________________ • Signature of Parent/Guardian: _________________________________

7. Excellence Without Excuse Form Academic Consultant’s Commitment We are committed to the following: We will arrive for academic mentoring sessions, prepared and on time. We will use proven researched-based teaching strategies and techniques to meet the needs of your child. We will always protect the safety, interest, and rights of your child. We will keep all academic records of your child confidential. We will always protect the safety, interest, and rights of all individuals in the classroom. __________________________ ____________________________SignatureSignature

8. Highly qualified, certified, and caring teachers Proven record of success in turning around low performance in students and schools Standards based instructional strategies Engaging researched-based learning activities Ability to track student performance over time Individualized analysis of student performance data Academic fitness, technology and exercises Affordable one-on-one academic tutoring Parent conferencing Student growth portfolios ACT and SAT Test preparation T We Offer the Following: Parents want their children to succeed and they are willing to take advantage of competent and rigorous academic tutorial and mentoring services necessary for students to succeed!

9. T Opportunities • Challenges and opportunities: • Failing students are a national problem. Currently, federal legislation has been enacted and designed to “Leave No Child Behind,” yet many students will be left behind without supplemental after school academic tutoring and mentoring. • The Accelerated Academic Achievement Academy is an opportunity to improve the academic fitness of children, including children with special needs. “Academic Fitness Is Our Business”

10. T Mission Statement • The Accelerated Academic Achievement Academy is Arkansas’ first premier tutorial and mentoring service designed to improve the academic performance of diverse learners, pre-k to grade 12, by using assessment data and parental input to address student strengths and weaknesses. • The Accelerated Academic Achievement Academy will help students acquire the confidence and scholarly performance skills necessary to score high on state and national tests and make better grades! “Academic Fitness Is Our Business”

11. T The Academic Team (A Team) • The Academic Team at the Accelerated Academic Achievement Academy includes distinguished scholars and educational professionals with advanced educational degrees, certifications and specialized training in various academic disciplines including: English, Advanced mathematics, Special education, Speech, Drama, Elementary education, Secondary education, Educational Assessments, Educational Leadership, Curriculum Specialist, Science, Reading, History. • The team has more than 75 years of K-12 educational excellence experience in teaching and educational administration in public and private institutions in Arkansas. • Years of research in teaching and learning indicates that the single most important factor in improving student performance is the quality of the teacher. All academic mentors in the Accelerated Academic Achievement Academy are licensed teachers with master’s and doctoral degrees in multiple areas. “Academic Fitness Is Our Business”

12. What Do Parents and Students Say About Us? • The atmosphere is professional, caring and student-centered. • We learn more than content, we also learn how the failure to learn will impact our future. • The academy is structured, the staff is tough, and we learn more! • They really help you prepare for college including reviewing your applications. • I feel like I am in academic aerobic class. It’s great! • They communicate with you about your child’s need, and make you a real partner in learning. “Academic Fitness Is Our Business”