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Tutor Connection - Tutoring Referral Form
Foster Youth Services Coordinating Program & Homeless Education Services
Please note that tutoring services require a MINIMUM commitment of 2 HOURS PER WEEK during the school year AND adult supervision during tutoring times. Also note tutoring starts in September for fall semester and January for spring semester.
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* Indicates required question
Referrer
*
Your answer
Referrer Phone Number
*
Your answer
Email
*
Your answer
Student Information
Student First Name:
*
Your answer
Student - Last Name:
*
Your answer
Gender:
*
Male
Female
Prefer not to say
Grade:
*
Your answer
Age:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
What days and times are best for tutoring
*
Your answer
School Attending:
*
Your answer
School District:
*
Your answer
Does the student receive any special education services?
*
504 Plan
IEP
No
Unknown
Other:
Student status:
*
Foster Youth
Released from Foster Care
Adopted
Guardianship
Homeless Youth, McKinney-Vento
Foster Youth, Probation
Kinship
Other:
Required
Tutoring Subjects Requested:
*
Math
Language Arts
Reading/Spelling
Science/Biology
Other:
Required
Tutoring Services Requested:
*
Please let us know if IN PERSON or VIRTUAL tutoring would work best for the student. If VIRTUAL is selected, please make sure student will have an available device to receive tutoring services virtually.
In Person
Virtual
Required
Caregiver Contact Information
Please identify the individual who the tutor will contact to make arrangements for tutoring sessions.
Caregiver - Full Name:
*
Your answer
Relationship:
*
Your answer
Caregiver - Address:
*
Please make sure to write out the caregiver's complete street address.
Your answer
City
*
Your answer
Caregiver - Phone Number:
*
Your answer
Caregiver - Email:
Your answer
If the caregiver is a non English speaker, please specify language:
Your answer
Child Welfare Services Information
Placement Type:
*
Resource Family Home
Foster Family Agency Home
Group Home/STRTP
Relative Caregiver
Other:
What region is the CWS Social Worker assigned to?
North Coastal
North Inland
North Central
Central
East
South
Adoptions
Extended Foster Care
Residential
Unknown
Clear selection
CWS Social Worker - Name:
Your answer
CWS Social Worker - Phone Number:
Your answer
CWS Social Worker - Email:
Your answer
Any additional information or accommodations requested (ie. tutor gender preference, ethnicity, tutoring language preference):
Your answer
Caregiver and youth are required to participate 2-3 hours every week for the entire semester. Caregivers will call tutor 24 hours in advance to cancel tutoring session. If tutoring is canceled more then 3 times you may not be eligible for tutoring. An adult will always be present during tutoring.
*
Yes
No
If the answer is no you are not eligible for Tutor Connection
Thank you!
After submitting this form you will be emailed a copy of your submission. We will do our best to match your student with a tutor.
If you have any questions, please contact Michelle Bailow at:
mbailow@sdcoe.net
or 858-298-2056
Thank you!
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