Tutor Referral Form
We’re pleased that you or your student is interested in joining our unique, high quality tutoring service. We believe that every student in foster care deserves the opportunity of a quality tutor. So that we may match appropriately, please fill out the below questions.

These tutors are trained volunteers with a subject matter or grade level expertise. They have committed to one quarter (3 months) of weekly face-to-face tutoring at your home or in a nearby public space, such as a library. As the quarter winds down, you and the tutor will decide on next steps. The tutors cannot transport a child or youth and, if in a home, another adult needs to always be present and tutoring must be done in the common area.
Your Name *
Your answer
Your Email *
Your answer
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Subject area or grade level requested for a tutor *
Specific, please.
Your answer
Current grade level *
School attending *
Your answer
Teacher's Name (with caregiver/student permission, the tutor will develop rapport with the teacher)
Your answer
Teacher's Email and/or Phone Number
Your answer
Social Service County *
If you selected "Other" (above), please type name of County:
Your answer
Social Service Case Worker Name *
(the tutor includes the student's progress in a monthly report)
Your answer
Caseworker Email *
Your answer
Social Service Supervisor Name
Your answer
Supervisor Email
Your answer
Caregiver Name: foster parent or group home contact *
Your answer
Caregiver Address *
Your answer
Caregiver Phone *
Your answer
Caregiver Email *
Your answer
Guardian ad Litem or CASA
(if applicable: name & email, as they advocate for every child in care)
Your answer
Adoption Worker/Supervisor
(if applicable: names & emails)
Your answer
How many hours of tutoring per week is requested? *
Availability for tutoring
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning (8am-12pm)
Afternoon (12-3pm)
After school (3-6pm)
Evening (6-8pm)
Submit
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