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2019-2020 Chicago Lights Tutoring Student Application
Student's First Name *
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Student's Last Name *
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Student's Gender or Gender Identity *
Address *
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Apartment Number
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City *
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State *
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Zip *
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Parent/Guardian First Name *
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Parent/Guardian Last Name *
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Relationship to Student *
Home Phone (please answer in (xxx) xxx-xxxx format)
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Parent Cell Phone (please answer in (xxx) xxx-xxxx format) *
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Work Phone (please answer in (xxx) xxx-xxxx format)
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Student Cell Phone (please answer in (xxx) xxx-xxxx format)
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Parent Email Address *
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Student Email Address
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Emergency Contact Name (different than parent) *
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Emergency Contact Phone Number (please answer in (xxx) xxx-xxxx format) *
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Emergency Contact Relationship to Student *
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Student Birth Date (please answer in xx/xx/xxxx format): *
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Student Age *
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Student's Grade in School Year 2019-2020 *
What category or categories best describes your race or ethnicity? Please check all that apply:
School *
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Teacher
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School Type *
If Applicable: CPS Student Email:
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