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Academic Mentor Program Registration Form
The purpose of The Academic Mentoring Program is to provide teens with a one on one experience in achieving academic success. This program will be more involved than just tutoring. The role of the academic mentor is to hold weekly meetings with the teen, hold them accountable to their school work, teach them study skills, help them set academic goals, and align them with the appropriate tutors, if they are unable to tutor a subject themselves.

The need for the academic tutoring program arose after watching several of our teens come to The Launch Pad to utilize the tutoring center, raise their grades initially, and then drop their grades upon becoming distracted by the drop in center and making new friends.

**Teens who are enrolled in the Academic Mentoring program are required to spend at a minimum of 30 minutes a day in the tutoring center until all of their grades are passing grades. The academic mentor and the tutoring center coordinator will hold teens accountable to this by checking their grades and helping them stay on track.

Student First and Last Name: *
Your answer
Student School Attending and Grade: *
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Parent First and Last Name: *
Your answer
Parent Email Address: *
Your answer
Parent Phone Number: *
Your answer
Academic Progress website/platform (i.e powerschool):
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Login Username and Password:
Your answer
Academic subjects and areas that your student is struggling with: *
Your answer
Academic subjects and areas that your student excels in: *
Your answer
What is your class schedule? (Please list all classes, with the teacher's name) *
Your answer
Who is your Academic Counselor at your school? *
Your answer
Do you have an IEP? (if yes, please be sure to bring in a copy to The Launch Pad Tutoring Center) *
Are you involved in after school activities or sports? If so, please list the activity and the days and times that you have a commitment with that activity. *
Your answer
I understand that by signing this form I am giving The Launch Pad Staff permission to view my child's academic progress and grades. I also understand that this information will be kept confidential *
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