Family Information

The Bertram Group

Your partners in educational excellence since 1994

Family Information

* required

Use this form if you have already spoken to a Bertram consultant who has asked for this information, which will be used to generate necessary paperwork, including an engagement letter and release form, if relevant.

Student Information

Student First Name *

Student Last Name *

Nickname

Birthdate *

Month

Day

Year

Student's Email *

Skype Name

Video Chat Mode and ID

Gender

Citizenship *

Dual Citizenship

School Information

Current School *

Currently in Grade *

Entering Grade *

Currently in Grade

Entering Grade

Expected Date of Entry, New School *

Expected Graduation Date, New School *

Siblings

Name	Grade
Name	Grade
Name	Grade

Parent Information

Household 1 (Defined as the primary residence of Student)

Parent 1 Name *

Defined as the primary contact

Spouse's Name

Parent 2 Name *

Address *

Country

Address 1

Address 2

City

State

ZIP code

Parent 1 Phone *

Parent 1 E-mail *

Parent 2 Phone *

Parent 2 E-mail *

Guardian Name *

Defined as the primary contact

Guardian Address *

Country

Address 1

Address 2

City

State

ZIP code

Guardian Phone *

Guardian E-mail *

Household 2

Parent 2 Name *

Spouse's Name

Parent 2 Address *

Country

Address 1

Address 2

City

State

ZIP code

Parent 2 E-mail *

Parent 2 Phone *

Who will sign the engagement letter and release form, (if appropriate)? *

May we send a copy of the forms to the other parent? *

To whom should the invoice be sent, if other than Parent 1 or Parent 2? *

Consultant Name *

Area of Interest *

Expected High School Graduation

Month

Day

Year

Service Request Date *

Immediately

Select date

Service Request Date *

Month

Day

Year

How did you hear about The Bertram Group? *

Name

Other

Where

Leave this field blank

The Bertram Group

Your partners in educational excellence since 1994

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Family Information