BGCBI: Mobile Tutoring Pre-Registration
Aloha Parent(s)/Guardian(s),
Thank you for your interest in our Mobile Youth Outreach Program. To be considered for the program please complete our Pre-Registration form below. Please note that completing this form does not guarantee your child(ren) a spot on this program. If you are eligible, a staff member will reach out to you to complete the registration process.

If you have any questions, please feel free to contact our Administrative Office at (808) 961-5536 or email us at mobiletutoring@bgcbi.org. Our office hours are Monday through Fridays from 9:00am-5:00pm
Email address *
Which Program Location are you applying for? *
All requested information must be completed or the pre-registration will not be accepted. Please complete one pre-registration form for each child applying for tutoring services. BGCBI Mobile Tutoring is for students in Elementary School (1st-6th grade) who live in the Pahoa, Kea’au, Ocean View, and Kona areas. Fixed location sites will also soon be opening. Keep posted for updates on our bgcbi.org website.
YOUTH'S INFORMATION
Student's Name *
Physical Address *
Please input complete address: Street, City, State, ZIP Code (Incomplete forms will NOT be accepted)
Date of Birth *
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Age *
Gender *
Current Grade Level *
Current School Attending *
PARENT/GUARDIAN INFORMATION
Relationship to Student *
Full Name *
Cell Phone *
Employer *
If you are currently not working please put "unemployed"
Work Phone *
If no work phone available please type "N/A"
Work Email *
If no email available please type "N/A"
FAMILY INFORMATION FOR FUNDING SUPPORT
(Please note that all personal information you share will remain confidential.)
Child's Ethnicity *
Please check all that applies
Required
ANNUAL HOUSEHOLD INCOME
Please note that all personal information you share will remain confidential. The more information we have about the communities we are serving, the more we can secure sufficient funding to continue to keep our programs free.
Total number of individuals that live in your household: *
Total number of children that live in your household: *
What is your household’s total annual income? *
Does your child receive free/ reduced school lunch? *
Does your family receive Food Stamps/EBT? *
Does your family receive the support of MedQuest? *
Child Lives with: *
Is your family currently homeless and in need of extra support? *
(example: currently living in a vehicle, tent, shack or unpermitted structure)
LEARNING ASSESSMENT
In what subject(s) is help needed? *
Required
Do you think your child is struggling in school? *
If yes, please explain
Do you think your child needs Study skills help? *
If yes, please explain
LEARNING STYLE
What is/are your child's learning differences or challenges? *
What is/are your child's personality type/ interests? *
SCHEDULE PREFERENCES *
What are good days & times for tutoring? Please list more than one day & time. Ex: Monday - Friday at 3pm; Ex: Monday, Wednesday, and Friday, at 9am
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When would your child be available to begin? *
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Is there anything else that will help us assist your child? *
How did you hear about us? *
By submitting this form, I certify the information provided above is true and correct to the best of my knowledge. *
BGCBI will accept this as an electronic signature.
Required
Please Read Before Submitting
Thank you for completing BGCBI's Pre-Registration form. Upon submitting this form you will receive a copy of this form in the email you provided.

Reminders:
Please note that completing this form does not guarantee your child(ren) a spot for this program. If you are eligible, a staff member will reach out to you to complete the registration process.
A copy of your responses will be emailed to the address you provided.
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