Student Name *

First Name

Last Name

Student Phone *

(###)

###

####

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Terms & Conditions *

We understand that plans may change. In the event that it is necessary to cancel your appointment, please call or email us as soon as possible; we require 24 hour notification. If you contact us less than 24 hours, you will forfeit your fee for that session. Payment is expected in advance or at the time of each session. We accept payment in the form of cash, credit, or check made out to Pimentel Academic Services. We can also securely store a credit card to charge at the time of each session. By selecting "agree," you hereby acknowledge and understand our terms and conditions, and you have been given full opportunity to discuss the implications with a representative of Pimentel Academic Services.

Agree