Tutoring Registration form

Name of Student*

First Last

Birth Date*

Gender*

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*

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.

Tutoring Registration Form

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TUTORING PROGRAM REGISTRATION

Tutoring Registration Form