Burlington School District
Supplemental Educational Services
2015 - 2016 Application
STUDENT INFORMATION (Completed by Parent/Guardian)
Student name_______________________________ Date of birth __________________
School __________________________________________
Grade _______________
Parent/guardian name_____________________________________________________
Home phone______________ Work phone___________ Cell phone________________
Address___________________________________ Email _______________________
Language spoken at home_______________________________________
As a parent/guardian of this student, I have selected the following agency to provide supplemental educational
tutoring services for my child. Additional information is available at each school’s main office.
Academic Associates (reading only)
Shader Croft School (grades 4-12)
Academic Tutoring Service
Stern Center for Language & Learning
Achieving Excellence (K-8 only)
Studentnest Inc
Arrowhead Tutors, Inc.
Sunglow Literacy Consulting
Believe to Achieve
Sylvan Learning
Eduwizards Tutoring Program
Tutorial Services (online only)
Kinetic Potential Scholars
Tutoring Revolution (1:1)
King Street Center
Variations Educational Services LLC
Laureate Learning Center Inc
1 in Learning Online LLC (online only)
Mobile Minds Inc
1 Online Tutoring LLC (online only)
One on One Learning
! ACHIEVE SUCCESS
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Burlington School District
Supplemental Educational Services
2015 - 2016 Application
I understand that:
1. The Burlington School District is obligated to pay up to the State-determined per pupil
allocation of $2727. Services will end for my child when that amount is reached. If I
want my child to receive services beyond that amount, I understand that I will be
responsible for payment.
2. My child must regularly attend the program. If he/she is absent more than three times,
my child will be dropped from the program.
3. Tutoring services will terminate on May 6, 2016 or when my child has utilized the per
pupil allocation for his/her tutoring, whichever comes first.
4. All transportation costs to and from the provider’s location are my responsibility.
5. I must attend a meeting with a representative of the provider and the school’s
representative to establish goals for my student.
6. If I cancel the tutoring service with this provider during the current school year, I may
not be allowed to select another provider until the next school year.
7. I understand that the fall enrollment period ends on September 25, 2015. If I miss the
deadline I will have another opportunity to enroll during January 2016.
SES RELEASE OF INFORMATION
By signing below, I grant permission for my child to receive services from an approved
SES provider. I give permission for Burlington School District to release educational
information to design tutoring sessions that meet the needs of my child. This may
include individual student information such as New England Common Assessments
Program (NECAP) scores, SRI and SMI test scores, WIDA test scores, report cards,
academic records, and attendance records. If my child receives special education
services or services under Section 504, I give permission for the District to share
his/her special education or Section 504 records, including his/her individual education
plan (IEP) or Section 504 plan. I also give permission for the SES Provider to share
any information regarding my child with appropriate personnel of the Burlington School
District. Student records/information will be kept confidential and will not be disclosed
to third parties or used for any purpose other than providing supplemental educational
services, documenting student progress, and evaluating the program.
_______________________________________
Signature of Parent or Legal Guardian
_____________________
Date
Please return the completed application to the main office of the school your child attends on
or before January 25, 2016.
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