Virtual Tutoring Request Form - Learn Well Services

Your students are close to getting the tutoring support they need!

Please complete the below form for each student in need of tutoring. After you’ve submitted the form, you will be contacted —usually within 24 hours—to confirm whether the student can be placed with a tutor at this time and will receive further instruction on how to proceed.

We’re looking forward to working with you to help the students in your district who are experiencing a medical absence stay on top of their schoolwork.

Please email us directly at virtualinstruction@learnwelleducation.com if you need any assistance.

First Name
Last Name
Parent First Name:
Parent Last Name:
Phone
Email
Street
City
State:
Zip
Grade:
Age:
Birthdate:
School:
School Contact:
School Contact Email:
School Contact Phone:
Subjects needs help with:
Length of Teaching:
Predetermined End Date:
Hours per week approved for:
Student Covered by IEP:
Learning Disabilities:
Scheduling Concerns:
How Long Has Student Been Absent:
Reason for Absence:
Special Instructions for Virtual Teacher:
School Referral Personnel Signature: