Myfortelearning services contract

MY

For te

Learning

10668 Eastborne Ave. Ste. 104 Los Angeles, CA 90024 (310) 717- 4594 www.MyForteLearning.com

Submission Date:

Please complete the following form in black or blue pen. If you filled out this form online, please check your answers, make any necessary corrections, and complete and sign the remaining information on the last three pages (pages four, five and six).

Student

First

Address

Middle Last

Home phone

Nickname

Student Email

Birthday

Age

Grade

Std. Cell

Gender

School

Below, please specify the relationship of each contact to the student (e.g.: Mother, Father, Grandparent, Step-Parent, etc.). Check the box(es) if this address is for Mailing, Billing, and/or Session Location.

Parent/Guardian Relation:

Address Mail Type:

Bill

Other Parent/Guardian

Session

Relation:

Name

Street

City

City State

Zip

Email

Zip

Hm

Fax

Hm

Fax

Wrk

Cell

Wrk

Relation:

Address Mail Type:

Bill

Accountant

Session

Please provide if you would like to be billed through your accountant.

Name

Name

Street

Street

City

City

State

Session

Email

Cell

Additional Contact

Bill

Name

Street State

Address Mail Type:

Zip

State

Zip

Work

Fax

Hm

Fax

Company

Cell

Wrk

Email

Has your child had any educational or psychological testing within the past three years?

If YES, by whom?

Referral Who referred you to us?

Testing

Name

Prefix Name

Profession

Profession

1

Report Available?

MY

For te

Learning

10668 Eastborne Ave. Ste. 104 Los Angeles, CA 90024 (310) 717- 4594 www.MyForteLearning.com

Submission Date:

Names of other adults in home (grandparent, housekeeper, etc.)?

Siblings names and ages:

Has your child ever repeated a grade?

If YES, which grade(s)?

List any medical conditions significant to your child’s well-being: Is you child currently receiving any medication(s)?

If YES, why is your child receiving medication?

Name of doctor who prescribed this medication:

Phone

Your child’s strengths at school: Your child’s strengths at home: Your child’s areas of need at school: Your child’s areas of need at home: Are your child’s sleep habits normal?

If NO, please elaborate: Has your child ever received any supplemental educational support (e.g., tutoring, educational therapy, special classes, visual training, or any other service related to his/her learning)?

Type of Service

Start Date:

End Date:

Start Date:

End Date:

Start Date:

End Date:

Describe your impressions of this service: Type of Service Describe your impressions of this service: Type of Service Describe your impressions of this service: What are your child’s extracurricular interests and/or hobbies?

Interests / Hobbies Time spent on activity (hours per week) When did this interest or activity begin?

Interests / Hobbies Time spent on activity (hours per week) When did this interest or activity begin?

Interests / Hobbies Time spent on activity (hours per week) When did this interest or activity begin?

If you will be receiving Individualized Educational Support, how do you expect it to benefit you and your child?

MY

For te

Learning

10668 Eastborne Ave. Ste. 104 Los Angeles, CA 90024 (310) 717- 4594 www.MyForteLearning.com

Submission Date:

Parent’s Evaluation of Child’s School and Outside-School Performance 4 = outstanding Area

3 = good

2 = satisfactory

Current Performance

1 = needs improvement Area

NS = not sure Current Performance

Reading - Decoding skills

Ability to ask for help at school

Reading - Comprehension skills

Peer relations

Spelling skills

Parent relations

Writing skills

Sibling relations

Math skills

Behavior at home

Recording assignments

Ability to complete chores at home

Note - taking

Ability to resolve conflicts

Copying from a whiteboard

Ability to ask for help at home

Copying from a book

Ability to work independently

Quality of homework

Backpack organization

Overal performance on tests & quizzes

Study area organization

Fine motor skills i.e. handwriting

School materials organization

Gross motor skills i.e. sports activities

Ability to organize thoughts

Behavior at school

Ability to recall information

Attitude toward school

Ability to get started on homework

Ability to manage school related anxiety

Ability to turn in homework

Ability to regulate emotions

Ability to sustain focus

Self image

Ability to pace work on long projects

Speaking skills

Energy level

Listening skills

Sleep habits

Rapport with teachers

General health

Class Grades Please provide the grade your child is currently getting. If you are unsure of any grade, please make the best guess.

Subject Math Science History English Foreign Language Other Course Other Course

Area / Level

Grade

MY

For te

Learning

10668 Eastborne Ave. Ste. 104 Los Angeles, CA 90024 (310) 717- 4594 www.MyForteLearning.com

Release of Information

Date:

I hereby authorize Lena Liu to give educational information and to receive educational and/or psychological information, including written records and files pertaining to my child,

Child’s Full Name This information will be utilized in an on-going basis to address my child’s educational, social and emotional needs.

Parent or Guardian signature

Print Name

Street Address

City

State

Zip

MY FORTE LEARNING Services Agreement This MY FORTE LEARNING Services Agreement ("Agreement"), effective as of _________________________ 2016 is entered into by , Parent(s)/Guardian(s) of (Child) and My Forte Learning, LLC, a California Corporation (“MY FORTE LEARNING”), for MY FORTE LEARNING Services for Child.

General Information/MY FORTE LEARNING Instructors MY FORTE offers a variety of services including educational consulting, personalizing curriculum and instruction, which Lena has developed throughout her career, which includes her Multiple-Subject Credential and Master’s from UCLA’s Teacher Education Program (TEP) and over 10 years of experience as an educational specialist in K-12 public and private sectors of education.

MY FORTE LEARNING Instructors will provide educational services to your Child.

MY FORTE LEARNING Instructors are experienced teachers and tutors with specialized training. All MY FORTE LEARNING Instructors are college graduates. MY FORTE LEARNING carefully pre-screens and conducts background checks on all MY FORTE LEARNING Instructors.

Terms of MY FORTE LEARNING Services 1) Fees: Parents and students are encouraged to attend a consultation with Lena Liu prior to receiving services. This is considered an Initial Consultation and is billed at the rate of $175.00 per hour. Any additional consulting services provided by Lena will be billed at $150.00 per hour for each sixty (60) minute session. Lena’s educational consulting services may include extended phone consultations with Parent(s)/Guardian(s), teachers, and other professionals working with Child, as well as time spent reviewing documents such as school reports, educational reports, and school transcripts. A travel fee of a minimum of fifty dollars ($50) may be assessed for any out of office consultations. The fee for Personalized Instruction, Intervention Math or Reading Instruction, and/or Educational Therapy session is eighty dollars ($80) (“Session Fee”) for each sixty (60) minute session. Sessions lasting more than sixty (60) minutes will be prorated in fifteen (15) minute increments. The minimum session length is sixty (60) minutes. The fee for MY FORTE LEARNING Personalized Schooling is forty dollars ($40) (“Session Fee”) for each sixty (60) minute session. Sessions lasting more than sixty (60) minutes will be prorated in fifteen (15) minute increments. Personalized Schooling requires a minimum of 15 hours of instruction per week and each student must be enrolled in a MY FORTE LEARNING-approved curriculum. The Personalized Academic Support rate of eighty dollars ($80) per hour will apply for any student working less than 15 hours per week and/or not enrolled in an accredited curriculum. The minimum session length is sixty (60) minutes.

2) Billings/Payments: All payments must be made directly to MY FORTE LEARNING and not to MY FORTE LEARNING Instructors. Parent(s)/Guardian(s) must enroll in our automatic payment plan. Parent(s)/Guardian(s) must sign and complete the Automatic

Credit Card Billing Authorization Agreement prior to beginning services. Payments will be charged to the credit card on file on the first and sixteenth (16th) of every month. If we are unable to process payment, services will be suspended until payment is received.

3) Early Release: Should Parent(s)/Guardian(s) or their authorized representatives choose to dismiss MY FORTE LEARNING Instructor before a session is scheduled to end, Parent(s)/Guardian(s) will still be responsible for Session Fee. 4) Additional Materials: Parent(s)/Guardian(s) are responsible for procuring all required educational materials. Please do not request Child’s MY FORTE LEARNING Instructor to purchase or procure any educational materials.

5) Preparation/Adult Supervision: Please have your Child ready and prepared for his/her session at the pre-arranged time. An adult is required to be at home while MY FORTE LEARNING Instructor is working with Child.

6) Work Finished Early/Missing: If Child finishes work early or if he/she does not have his/her study materials, your MY FORTE LEARNING Instructor will have a variety of relevant learning activities to do with Child.

7) Scheduling: All scheduling must be done directly with your Instructor.

8) Cancellations/Rescheduling: All cancellations and rescheduling must be done at least twenty-four (24) hours prior to scheduled appointments and must be done directly with your MY FORTE LEARNING Instructor. Parent(s)/Guardian(s) are responsible for the full Session Fee for sessions that are cancelled, with or without notification, or rescheduled fewer than twenty-four (24) hours prior to scheduled appointments.

Exceptions can be made in the event of a sudden illness or emergency, in which case, Parent(s)/Guardian(s) should contact both the MY FORTE LEARNING Instructor and the MY FORTE LEARNING office as soon as possible. Should Child arrive late and request a full session, Parent(s)/Guardian(s) will be charged for the full session time, plus the time your MY FORTE LEARNING Instructor spent waiting.

9) Missed Sessions: Should MY FORTE LEARNING Instructor arrive and find no one home, MY FORTE LEARNING Instructor will wait thirty (20) minutes. After twenty (20) minutes, MY FORTE LEARNING Instructor will leave, recording the time he/she arrived and left. In such cases, Parent(s)/Guardian(s) will be charged the full Session Fee. 10) Conferences/Meetings with MY FORTE LEARNING Instructors: Conferences and/or meetings with MY FORTE LEARNING Instructors are billed at the Session Fee. The minimum session length is sixty (60) minutes. Meetings lasting more than sixty (60) minutes will be prorated in fifteen (15) minute increments. Should MY FORTE LEARNING Instructor be requested to participate in a phone conference, the Session Fee will be prorated in fifteen (15) minute increments. Should MY FORTE LEARNING Instructor be required to travel a significant distance to attend a meeting, a travel fee may be charged. Rates vary according to time and distance.

11) External Academic Support: Should your MY FORTE LEARNING Instructor be requested to provide additional academic support outside of a scheduled session via email, phone, or by any other means, the Session Fee will be prorated in fifteen (15) minute increments.

12) Orientation Session: In order for services to be successful, MY FORTE LEARNING recommends a one (1) hour orientation session with MY FORTE LEARNING Instructor.

During this orientation session, MY FORTE LEARNING Instructor will help Child organize his/her work area and study materials. The work environment must include the following: a. A clean, quiet, and well-lit working space; b. A large table or desk and two comfortable chairs; c. Adequate storage space for school materials; d. All items on the “Required Materials List.” (Please see attachments) 13) MY FORTE LEARNING Center: If Child will be receiving services on site at the MY FORTE LEARNING Center, Parent(s)/Guardian(s) will be required to read and sign the MY FORTE LEARNING Center Parent/Student Handbook prior to beginning services.

14) Exclusivity: a. Parent(s)/Guardian(s) will not establish a separate work arrangement with any personnel provided by MY FORTE LEARNING. This includes, but is not limited to: MY FORTE LEARNING Instructors, Math & Language Arts Specialists, Shadows and One-on-One & Schooling Instructors. b. Parent(s)/Guardian(s) understand and acknowledge that MY FORTE LEARNING Instructors and other MY FORTE LEARNING personnel are under contract with MY FORTE LEARNING and are prohibited from accepting employment from Parent(s)/Guardian(s) or providing services directly to Child or Parent(s)/Guardian(s)’ family for the duration of their contract with MY FORTE LEARNING and for a period of two years after termination of their contract with MY FORTE LEARNING. 15) Indemnification: Parent(s)/Guardian(s) shall indemnify, defend and hold MY FORTE LEARNING, and its officers, directors, employees, agents, representatives, instructors, and Lena Liu harmless from and against any and all claims, demands, suits, losses, liabilities, damages, costs, expenses and judgments of every kind and description whatsoever, including, but not limited to reasonable attorney’s fees, arising out of or in any way related to the negligent or willful misconduct by Child, Parent(s)/Guardian(s)their representatives or agents, including but not limited to teachers or their breach of any of the terms set forth in this Agreement.

16) Mediation/Arbitration/Applicable Law: If any disputes arise between the Parties concerning this Agreement, they shall first attempt resolution by mediation before a professional mediator. If this fails, or if the mediation is not concluded within thirty (30) days of a written request for mediation, the Parties shall submit any dispute to binding

arbitration before a single arbitrator who shall be a retired Judge with JAMS or the Alternative Resolution Centers (ARC). The costs of mediation and arbitration shall be split equally between the Parties. This provision shall not prevent a party from seeking immediate injunctive relief under appropriate circumstances. This Agreement and all related disputes shall be interpreted according to California law, and the sole and exclusive venue for all disputes, mediations, arbitrations, or suits shall be Los Angeles County, California. The Parties consent to jurisdiction in Los Angeles County, California.

17) General Provisions: This Agreement supersedes and replaces all other agreements, either oral or in writing, between the Parties with respect to its subject matter. Each Party acknowledges that no promise or representation has been made by any Party or Party representative that is not contained in this Agreement and that no agreement, representation, or promise not contained in this Agreement is valid or binding. No breach of any provision of this Agreement may be waived unless in writing, and any waiver is not a waiver of other acts or provisions. The rights and obligations of MY FORTE LEARNING under this Agreement shall inure to the benefit of and shall be binding upon the successors and assigns of MY FORTE LEARNING. Parent(s)/Guardian(s) may not assign his/her rights and obligations under this Agreement. This Agreement may be signed in counterparts, each of which shall be deemed an original.

I have read and accept the terms and conditions of this Agreement.

My Forte Learning, LLC

Parent/Guardian By:

By:

Print Name:

Sign Name

Lena Liu, President

Date

MY

For te

Learning

10668 Eastborne Ave. Ste. 104 Los Angeles, CA 90024 (310) 717- 4594 www.MyForteLearning.com

AUTOMATIC CREDIT CARD BILLING AUTHORIZATION AGREEMENT I, the undersigned, hereby authorize My Forte Learning Services, Inc., to automatically charge my Visa, MasterCard, or American Express twice a month for any and all services rendered in connection with my child, .

Credit Card Type:

Visa

Mastercard

American Express

Cardholder’s name as it appears on Credit Card:

Credit Card Number: Expiration Date:

Security code:

Billing Address: Street

City

Zip Code

I accept and agree to the terms and conditions of the My Forte Learning “Automatic Credit Card Billing Authorization Agreement.” If My Forte Learning is unable to process my payment, I will be responsible for an alternate payment arrangement and any late fee that results.

I may cancel this Automatic Credit Card Billing Authorization Agreement at any time by submitting written notification to the My Forte Learning office.

By signing this authorization, I acknowledge that I have read and agree to all of the above. All information given is complete and accurate.

Signature of Card Holder: Printed Name of Card Holder:

Date: