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TUTORING PROGRAM REGISTRATION
Tutoring Registration form
Kelli Holleman
2022-08-19T08:37:49-04:00
Tutoring Registration Form
Name of Student
*
First
Last
Birth Date
*
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Gender
*
Male
Female
School Attended
*
Grade Level
*
Teacher name and email (optional)
* Teacher will be contacted with parent's permission
Please check the level of need in the areas that apply below.
*
Math - low level of need
Math - high level of need
Reading and Writing - low level of need
Reading and Writing - high level of need
Science - low level of need
Science - high level of need
Physical Activity - low level of need
Physical Activity - high level of need
Other
* To track student progress, please provide a copy of quarterly report cards and progress reports to the tutors.
Additional Comments
Medical or Allergy Issues - write "None" if there are no issues.
*
* Snacks and drinks will be provided.
Parent Name(s), Phone Number(s) and Email address(es)
*
Emergency Contact Name and Phone #
*
Housing Program
*
My Father's House
MaC
Teaching Housing
Annex
Consent
*
I agree.
Tutoring at MaC House:
All students are to be picked up by CCM staff at the B&G and walked over to MaC House for Tutoring services. Parents will pick up their students no later than 6 pm.
Tutoring for students at the Annex:
Tutoring will take place inside Memorial Baptist Church, in a study room near the CCM Office. For dismissal, staff will walk the students over to the Annex around 6:00 p.m. – parents must be present in the home.
All families must inform the CCM staff of the student’s absence at least an hour before the session starts. Also, inform staff of alternative pick-up arrangements from another adult. To track student progress, please provide a copy of the student’s quarterly report card. Snacks and drinks are provided, but modifications aren’t guaranteed.
Initial
*
Thank you for your interest in our Tutoring Program!
Email
This field is for validation purposes and should be left unchanged.
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