Student Application Form
Tell us about your family!
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Email *
Student First Name *
Student Last Name *
Student Birthdate: *
MM
/
DD
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YYYY
Gender *
Student Current Grade: *
Address *
City *
State *
Zip *
County *
Parent/Guardian Name *
Parent/Guardian Phone *
Emergency Contact: NAME & PHONE *
How did you hear about us? *
What is the student currently passionate about?
Additional information that might be helpful in working with your student.
School *
District *
If your district isn't listed, enter below:
Has your child attended the DLC before? *
WHILE WE RESPECT THE PRIVACY OF OUR 
FAMILIES, WE ARE REQUIRED TO REPORT 
THE FOLLOWING DEMOGRAPHIC INFORMATION 
IN GRANTS USED TO FUND OUR PROGRAMS. 
THIS INFORMATION WILL NOT BE SHARED 
OR USED IN ANY OTHER WAY EXCEPT FOR 
THE AFOREMENTIONED PURPOSE ABOVE. 

Do you AGREE with the privacy statement?
 *
Does the student have an Individual Education Plan (IEP)? *
Are you a female Head of Household? *
Is your student eligible for the free & reduced lunch program *
Ethnicity *
Race *
Number of individuals in your home *
Annual Income *
Do you have home internet (not including cell phone)?
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If no, please check the reason why below:
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PROGRAMMING
Our Culturally Responsible STEM Based Programming
Each of our sessions is lead by culturally responsible community volunteers and every session provides a STEM component. We focus on Math on Saturdays and Reading on Mondays.
select one or more! *
Required
Partner Offerings at the Dubois Learning Center 
(check the box if you're interested AND email the partner for more information)
Family Partnership Agreement
How you can help us add value to your experience with us!

Students

· Be prepared to learn and have fun (bring homework)

· Plan and commit to set aside study time each day (homework, reading, or practice drills)

· Enter and leave the session in a quiet and orderly manner

· Horseplay and loud noise/voice are not acceptable.

· Be Respectful of others (coaches and fellow students)

· No eating or drinking is allowed during session

· Take care of restroom and water breaks prior to our sessions

· Cell Phone should be turned off and put away during sessions

Parents

· Ensure consistent attendance, make time with us a priority

· Be sure children are well fed and well rested

· Be on time– arrive at least 5-10 minutes before start and end time

· Make sure your child understands that all cell phones must be put away during class times.

· Ask your children about their progress – share specific concerns with your child’s coach.

· Plan and encourage a minimum of 30 minutes of study time each day

· Share feedback so that we are better able to understand and meet your needs

· Support the Learning Center by volunteering your time and/or participating in activities.

· We would like a copy of your child’s grade cards to help us determine their progress at the end of each quarter.


The following activities will not be tolerated and depending upon the situation and circumstance, children may be permanently removed from the program:

· Profanity

· Disrespect of persons or property, failure to meet above listed expectations

· Blatant lack of attention, lack of initiative, or interest in learning

· Inappropriate Dress- Students who wear clothing which is improperly fitted or is otherwise a significant disruptive influence on the learning-teaching environment will be requested to meet with the Program Director.

I have read, understand and agree to commit to the expectations in the Family Partnership Agreement
 *
By checking yes below, I agree with and understand my child may be photographed while participating in Learning Center services, AND that these photographs could be used as future marketing material for Learning Center services.
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A copy of your responses will be emailed to the address you provided.
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