Dept. of Rehab

Name *

First

Last

Email *

Phone Number + Extension *

I authorize the mentioned student to receive tutoring services within the above mentioned dates. *

Yes

Please read our Tutoring Policy and accept the terms below. By checking the box, you have agreed to the Tutoring Policy Terms and all it entails. For further questions or clarifications, please give us a call at (714) 991-3838.

I accept the terms & conditions in the Tutoring Policy *

I Agree

Tutoring Start Date *

Tutoring End Date *

Number of Tutoring Hours per Week *

Tutoring is contracted at $55 per hour.

Site Info:

Supplier ID: BID0053272
Certification Number: 2006739
Vendor Number:

department of rehabilitation

DOR Referral Form

Counselor Information:

Student Information: