You must have JavaScript enabled to use this form. 1 Start 2 Page 2 3 Page 3 4 Page 4 5 Complete Select up to four choices: Course Selection: * General Reading Support Intensive Reading Support General Math Support Intensive Math Support Homework Help Student information (please enroll only one student at a time. Complete additional form for each additional child enrolled): EMIS Number: * Student Name/Gender/Grade: 1. Daytime Teacher Name: * Please enter this information for tutees who participate in tutoring DURING the school day 1. Student Name: * 2a. Student Gender: * Male Female Rather Not Say Other... 2a. Student Gender: Other... 2b. Student Race: * Caucasian African American Native American Hispanic Native Hawaiians or Pacific Islander Middle Eastern Other... 2b. Student Race: Other... 3. Grade: * Pre-K K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 4. Medium of Regular School Instruction: * Hybrid Remote In-Person 5. Disability Status * Yes, please describe No If yes, please describe: * If yes, please include IEP goals: * Parent/Guardian Contact Info (Primary): 6. Preferred Method of Contact/Permission (Primary): * Call Text Email 7. Name (Primary): * 8. Phone Number (Primary): * 9. Email (Primary): * Parent/Guardian Contact Info (Secondary): 10. Preferred Method of Contact/Permission (Secondary): Call Text Email 11. Name (Secondary): 12. Phone Number (Secondary): 13. Email (Secondary): Student Contact info (usable by student) 14. Phone Number (if applicable): 15. Email (if applicable): 16. Devices Available for Use (Select all that Apply): * Phone Laptop PC Tablet Printer Other... 16. Devices Available for Use (Select all that Apply): Other... 17. Programs/Applications Used/Approved for Student use during Tutoring: * Microsoft Office Google Classroom YouTube Other... 17. Programs/Applications Used/Approved for Student use during Tutoring: Other... Leave this field blank
