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Harambee Program-Tutoring Intake Form
Generously funded by The County of Simcoe. Parents Against Racism Simcoe County is excited to be able to offer this support to the community. We have implemented a sliding scale model, that will allow us to ensure everyone can access services regardless of income. If you need help with this form or have any questions, please email harambee@parsc.ca or call 705-623-9791
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Child's grade
Parent/Caregiver first and last name *
Child first and last name *
Child's date of birth *
MM
/
DD
/
YYYY
Child's grade in school *
Full address, including postal code. (We do mail out and drop off materials for some sessions. Please check this info is correct) *
Does your child use Lexia (reading program) at school?
Clear selection
Email *
Confirm email *
Phone number *
Confirm phone number *
How does the child identify? *
Emergency contact information, is it the same as above? *
If no, list emergency contact information here-Full name, address with postal code and phone number
Relationship of emergency contact *
Please list any diagnosis or learning needs  the tutor should be aware of. 
Does your child have an IEP? (Individual Education Plan)  *
Required
Please select the session you would like to register for *
Required
Do you have interest in Empowerment Academy? A program that focus on a path to success for Black students, fostering academic achievement, leadership development, and a strong sense of cultural identity. *
Required
Do you require support with transportation?  *
Required
Do you need to borrow a Chromebook? (For virtual sessions) *
Required
Tell us about your child's likes, dislikes etc.  *
Please indicate your income range. *
Are you interested in a monthly subscription, that allows access to 2 sessions a week? *
Required
Additional comments
The information you have provided above is truthful and you consent to PARSC contacting you.
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Required
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