Child's Name
*
First Name
Last Name
Preferred tutoring day
*
Monday
Tuesday
Wednesday
Thursday
Date of Birth
*
MM
DD
YYYY
Grade in School
Race (Please check all that apply)
Gender
Female
Male
Gender Nonconforming
Food allergies, seasonal allergies or other health concerns we should know about?
*
Does your child have an Epi-Pen?
Yes
No
Does your child have a diagnosed learning disability? If yes, please explain:
*
Child's Interests and Hobbies:
Child's T-Shirt Size?
Child's School
*
Primary Teacher's Name
First Name
Last Name
Teacher's Email
Teacher's Number
(###)
###
####
Tutoring Needs (Please check all that apply)
*
If you checked "Additional Needs," please explain below:
Caregiver's Name
*
First Name
Last Name
Relationship to the student
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
(###)
###
####
Email:
*
Emergency Contact #1
*
First Name
Last Name
Relationship to the student
Phone Number
*
(###)
###
####
Emergency Contact #2
*
First Name
Last Name
Relationship to the student
Phone Number
*
(###)
###
####
Does your child receive free or reduced lunch?
No
Yes
How many people are in your household?
Please select your approximate annual income range to assist us in our grant writing endevours:
