VAST
VASSAR AFTER SCHOOL TUTORING
NEW SCHOLAR APPLICATION Student Name: _________________________________________________________________________________ First Last M.I. Grade: _______ Age: __________ Gender: _____________ Race/Ethnicity: ___________________________ Parent/Guardian 1 Name: ___________________________________________________________________________ First Last M.I. Parent/Guardian 2 Name: ___________________________________________________________________________ First Last M.I. Parent/Guardian Contact Information Home Address: _______________________________________________________________________________________ _______________________________________________________________________________________ Home Phone: _____________________________________ Cell Phone: _____________________________________ Which is better to contact? (Please circle) Home Phone Cell Phone Email Address: ________________________________________________________________________________________ Parent Occupations: __________________________________________________________________________________ What is the best day of the week and time for you to attend VAST meetings/events? _________________________________________________________________________________________________________ What language(s) do you speak at home? __________________________________________________________ Emergency Contact [ ] Please check here if emergency contact person is same as Parent/Guardian 1 above. If different from above, please write emergency contact information below: Emergency Contact Name: ___________________________________________________________________________ Relationship to Student: _____________________________________________________________________________ Emergency Contact Phone: __________________________________________________________________________ Please return this application as soon as possible to the VAST Mailbox at the PMS Main Office or to the mailing address listed on the last page. VAST
VASSAR AFTER SCHOOL TUTORING
General Permission Slip 2013-­‐2014 I, _____________________________________________________, grant my child ________________________________________ permission to participate in the Vassar After School Tutoring (VAST) program at Poughkeepsie Middle School. I give permission for my child to go on informal walking field trips in the surrounding neighborhood of the middle school under the supervision of VAST tutors and administrators. • VAST will occur on Mondays, Wednesdays, and Fridays afterschool, from 2:55-­‐4:30pm. Does your child participate in other activities that may conflict with VAST? [ ] Yes [ ] No If so, what activity? (Sport, dance, school clubs, church activity, etc.) : ________________________________________________________________________________________________ Please check which days (if any) your child will NOT attend VAST because of conflict: [ ] Mondays [ ] Wednesdays [ ] Fridays PARENT/GUARDIAN SIGNATURE: _______________________________________
DATE: _______________________ Please return this application as soon as possible to the VAST Mailbox at the PMS Main Office or to the mailing address listed on the last page. VAST
VASSAR AFTER SCHOOL TUTORING
NEW SCHOLAR APPLICATION For the student to fill out: What school subject do you like best? _____________________________________________________ What school subject is most difficult for you? _____________________________________________ What do you want to be when you grow up? Why? _________________________________________________________________________________________________ _________________________________________________________________________________________________ What is the last book you read? What did you like about it? What didn’t you like about it? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Write three activities you like to do when you are not in school: 1. ______________________________________________________________________________________________ 2. ______________________________________________________________________________________________ 3. ______________________________________________________________________________________________ Do you have any brothers or sisters? How old are they? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Turn over to answer questions on back-­‐-­‐-­‐-­‐à Please return this application as soon as possible to the VAST Mailbox at the PMS Main Office or to the mailing address listed on the last page. VAST
VASSAR AFTER SCHOOL TUTORING
NEW SCHOLAR APPLICATION For the student to fill out: Please write one paragraph answers (4-­‐5 sentences each) to the two questions below. 1. Why do you want to be in the VAST program? 2. Who is one of your heroes? Why do you look up to this person? What do you learn from him or her? (It can be a real person or a fictional character.) Please return this application as soon as possible to the VAST Mailbox at the PMS Main Office or to the mailing address listed on the last page. VAST
VASSAR AFTER SCHOOL TUTORING
NEW SCHOLAR APPLICATION For the student to fill out: Please list the academic classes you are taking this school year and your teachers’ names below. VAST might use this information to ask your teachers about what you’re learning so we can best help you with your homework. Period Course Name Teacher Name 1 2 3 4 5 6 7 8 Homeroom Homeroom Thank you for filling out this application! You can return it to the PMS Main Office or mail to the address below: Vassar College Urban Education Initiative-­‐ VAST Box 709 124 Raymond Avenue Poughkeepsie, NY 12604 If you have any questions, call Rachel Gorman, VAST Coordinator, at 437-­‐5987. Please return this application as soon as possible to the VAST Mailbox at the PMS Main Office or to the mailing address listed on the last page.