Request edit access
Harambee Program-Tutoring Intake Form
Generously funded by The County of Simcoe. Parents Against Racism Simcoe County is excited to be able to offered this support to the community. Please note we will begin to reach out to families the week of March 25th. If you need help with this form or have any questions, please email harambee@parsc.ca
Sign in to Google to save your progress. Learn more
Child's grade
Parent/Caregiver first and last name *
Child first and last name *
Full address, including postal code *
Child's date of birth *
MM
/
DD
/
YYYY
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) 
Please pick the preferred mode of service. PARSC will do our best to accommodate your request.
You may pick both options.
 *
Required
What subjects do you want support for? 
You may pick more than 1.
 *
Required
Currently there is limited funding and therefore the focus is on math and reading. Do you have interest in paying for tutoring in additional subjects? For example French.
Clear selection
If 'Yes' please list the subject/s
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
Tell us about your child's likes, dislikes etc.  *
Please indicate your income range. *
Additional comments
The information you have provided above is truthful and you consent to PARSC contacting you.
 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Parents Against Racism Simcoe County.

Does this form look suspicious? Report

Google Forms