2011-2012 FREE TUTORING Supplemental Educational Services Directions: Please complete all sections of this form. Please print LEGIBLY and submit the completed form to your child’s school. __________________________________________________ _______________________________________ ______________ Student Last Name Student First Name Grade _________________________________________________________________________ _______________ __________________ School Name Date of Birth ____________________________________________________________________________________________________________ Address _____________________________________________________ _______________________ ___________________________ City State Zip Code _____________________________________________________________ ____________________________________________ Parent’s Last Name Parent’s First Name ____________________________ ______________________________ ____________________________________________ Parent’s Primary Phone # Parent’s Cell Phone # Parent’s Email Address Select Provider(s): Please select three different providers as your 1st, 2nd, and 3rd choice by checking the appropriate circle(s) in the space provided below. Only 1 circle per choice. 1st Choice o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o 1 to 1 Tutor A+ Academics A+ Tutors for Scholars Abacus In-Home Tutoring ABLE Tutoring Accuracy Temp Services (ATS) Achievia Tutoring Midwest Alternatives Unlimited Applied Scholastics Carver Learning Systems Christian Fellowship Circle of Light Club Z! In-Home Tutoring College Nannies & Tutors Educate Online Grace United Group Excellence Growing Scholars Huddle Learning Innovative Educational Programs Kansas City MO School District Learning4Today Learn It Online Learn It Systems Leatherwood Enterprises Millennial Academy MO Learning Unlimited Project Life Impact Reunited Counseling & Training SLC of Lee’s Summit Success for Today & Tomorrow Swope Corridor Renaissance Terry Learning Tolbert Tutoring Tutors With Computers Village Learning Solutions W.E.B. Dubois Learning Center 2nd Choice o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o 1 to 1 Tutor A+ Academics A+ Tutors for Scholars Abacus In-Home Tutoring ABLE Tutoring Accuracy Temp Services (ATS) Achievia Tutoring Midwest Alternatives Unlimited Applied Scholastics Carver Learning Systems Christian Fellowship Circle of Light Club Z! In-Home Tutoring College Nannies & Tutors Educate Online Grace United Group Excellence Growing Scholars Huddle Learning Innovative Educational Programs Kansas City MO School District Learning4Today Learn It Online Learn It Systems Leatherwood Enterprises Millennial Academy MO Learning Unlimited Project Life Impact Reunited Counseling & Training SLC of Lee’s Summit Success for Today & Tomorrow Swope Corridor Renaissance Terry Learning Tolbert Tutoring Tutors With Computers Village Learning Solutions W.E.B. Dubois Learning Center 3rd Choice o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o 1 to 1 Tutor A+ Academics A+ Tutors for Scholars Abacus In-Home Tutoring ABLE Tutoring Accuracy Temp Services (ATS) Achievia Tutoring Midwest Alternatives Unlimited Applied Scholastics Carver Learning Systems Christian Fellowship Circle of Light Club Z! In-Home Tutoring College Nannies & Tutors Educate Online Grace United Group Excellence Growing Scholars Huddle Learning Innovative Educational Programs Kansas City MO School District Learning4Today Learn It Online Learn It Systems Leatherwood Enterprises Millennial Academy MO Learning Unlimited Project Life Impact Reunited Counseling & Training SLC of Lee’s Summit Success for Today & Tomorrow Swope Corridor Renaissance Terry Learning Tolbert Tutoring Tutors With Computers Village Learning Solutions W.E.B. Dubois Learning Center By signing this document, I authorize Kansas City, MO School District (KCMSD) to release my child’s name, address, phone number, demographic and academic information in addition to my own contact information to the SES/Free Tutoring providers that I have selected above, to which my child may subsequently sign. I further authorize KCMSD to release this information electronically and in hard copy. _____________________________________________________________________ ___________________________ Parent’s Signature Date Please return the registration form to your child’s school by January 27