After School Tutoring Application
Date: _____________________
Student Name: _____________________________________________
Home School: ____________________________
Grade: ________
Gender: M_____
F_____
Parent/Guardian Name: __________________________________________________________________
Home Phone: _______________________________ Work Phone: ______________________________
Cell Phone: __________________________
Email: ___________________________________________
**PLEASE CIRCLE EACH CLASS BELOW FOR WHICH TUTORING SERVICE IS BEING REQUESTED**
ENGLISH
MATH
SCIENCE
SOCIAL STUDIES
READING
Te a c he r:
G ra de Ave ra ge :
***Please fill in the name of the classroom teacher(s) and the grade the student received for the last grading period for the course(s) circled above***
PARENT/GUARDIAN’S COMMENTS: _________________________________________________________________________
_______________________________________________________________________________________________________
1.
Students will be tutored in 50 minute time blocks.
2.
Please circle the day you prefer to bring your student:
Monday / Wednesday (Central & Brink)
Tuesday / Thursday
3.
4.
Please list your 1st, 2nd, and 3rd choice of location:
___________
___________
___________
___________
Brink
Central
Highland East
Highland West
___________
Moore West
Please circle the time block best suited to meet your transportation needs.
4:30-5:20
5.
(Moore West, Highland West, & Highland East)
5:30-6:20
6:30-7:20
Is this student enrolled in any other special programs? _____Yes _____No
If yes, please list programs _____________________________________________________
6.
______ Yes, I do want tutoring for my child
______ No, I do not want tutoring for my child
NAME OF SCHOOL COUNSELOR: _________________________________________________________________
PARENT/GUARDIAN SIGNATURE: __________________________________________________________________
**PLEASE RETURN TO SCHOOL COUNSELOR AS SOON AS POSSIBLE.**