2015 SUMMER LITERACY TUTORING PROGRAM APPLICATION
APPLICATION FOR THE SPRING 2016 LITERACY TUTORING PROGRAM
Child’s Name:_________________________________________________ Grade in Fall 2015:_________
School:_________________________________________________________________________________
Complete a separate application for each child. When submitting applications for two or more children in the
same family, tuition is $100 for the first child and $75 for each additional child. No tuition is due at this time.
Tuition is payable upon acceptance into the program. Financial support is available to families in need. For
financial support information contact: Prof. Sam Slotnick at 845-257-2809 or slotnics@zmail.newpaltz.edu.
The Spring 2016 Literacy Tutoring Program consists of twelve (12) sessions. Children will attend either the
Monday or Tuesday sessions. For session meeting dates, please see the Spring 2016 Candidate-Student
Meeting Schedule at the website: www.newpaltz.edu/literacycenter.
Mondays: Beginning February 8 from 5:15 PM to 7:00 PM
Tuesdays: Beginning February 9 from 5:15 PM to 7:15 PM
Please circle the section you are submitting this application for.
Submission of this application implies a commitment to have applicant child attend all twelve (12)
sessions as per the Candidate-Student Meeting Schedule provided online.
Parent/Guardian Name: ____________________________________________________________________
Complete Mailing Address: _________________________________________________________________
Email: _____________________ Phones: (home) ___________ (cell) ____________(work)___________
Signature of Referring Educator:____________________________________Title: ______________________
Name (Print):________________________________________ Phone (_________)______________________
Email:____________________________________________________________________________________
With each application, include a completed EDUCATIONAL RECORDING AND CONSENT RELEASE
FORM (ERCRF) available at www.newpaltz.edu/literacycenter . Places in the program are not reserved and
submission of an application is not an assurance of acceptance.
Please return completed this two-page Application and Release Form to:
Prof. Sam Slotnick, Literacy Center Coordinator
Department of Elementary Education
School of Education-Old Main – B101
SUNY at New Paltz
New Paltz, NY 12561
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2015 SUMMER LITERACY TUTORING PROGRAM APPLICATION
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2015 SUMMER LITERACY TUTORING PROGRAM APPLICATION
REFERRAL QUESTIONNAIRE FOR_________________________________
This questionnaire should be completed by the referring educator listed on page 1 of this application.
Information provided in this questionnaire is kept confidential and is used to support the applicant’s literacy
tutoring should he/she be accepted into the program.
1. What is the primary reason(s) this student is being referred for literacy tutoring at this time?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2.
Please describe the support (AIS, reading teacher, RTI services, intervention, etc.) this student received,
if any, during the past (2014-2015) and current (2015-2016) school year.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3.
If possible, please provide current literacy assessment results that could inform this student’s literacy
tutoring program.
Assessment
Additional Comments:
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Results
Date
Obtained