The Tutor Me Program Student Enrollment Application
The Tutor Me Program is an after school program that is held September - May each school year. We offer personalized 1:1 tutoring services to students grades K-12. Our services cover tutoring, homework help, and test/exam studying. Our goal is to help your child better understand any subject that is troubling them. At this time, all sessions are held at a public library to near your home.
One application per student. All sessions are $15.00 per hour, students receive 2 sessions per week. If you would like in home sessions that is a $10 extra charge per session.
Student Name: *
Your answer
Date of Birth & Age: *
Your answer
Grade: *
Your answer
School District: *
Your answer
School Attending/Address/Phone: *
Your answer
Legal Parent/Guardian Name(s): *
Your answer
Are you the legal guardian of this student and assume all responsibilities? *
Address, City, State, Zip:
Your answer
Contact Number (Cell/Home): *
Your answer
Email Address: *
Your answer
Employer’s Name: *
Your answer
Employers’ Address: *
Your answer
City/State/Zip Code: *
Your answer
Emergency Contact Information:
Please enter an emergency contact information for this student.
Name: *
Your answer
Address: *
Your answer
City/State/Zip Code: *
Your answer
Contact Phone (Cell/Home): *
Your answer
Relationship: *
Your answer
Your child's application must be completed before services can begin. This will serve as a starting point for the Tutor Me Program (to see where your child is at academically). Please be advised that your student must also to take an Entry and Exist Assessment Exam as a part of our data collection report.
Preferred Sessions: Limit up to 2 sessions per week *
Required
Please check here for your consent to take pictures and video of your student’s participation in the program and to be used solely for media content. *
Required
Subject Strength(s): *
Your answer
Subject Weakness(s): *
Your answer
Subjects Needing Tutoring In (Limit 2) : *
Your answer
Does your child have a quiet place to study (if so, where?): *
Your answer
Hours Spent on Homework a Night: *
Your answer
Hours Spent Reading a Week: *
Your answer
Does your child complete his/her homework studies near or in front of a: television, game system, radio, or any other entertainment that causes distractions? *
Is there any down time during the evening time where you can relax and read a good book, study, or complete your homework? *
Your answer
Extracurricular Activities/Sports: *
Your answer
Signature (Please type your name below): *
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