Community Club Tutor Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

If you have any questions about this form, please contact Phil Telfeyan at ptelfeyan@communityclub.org.

Please use initial capitalization on proper nouns.

First and Last Name
*

Please enter your first and last name (no middle name). Please use initial capitalization.

Nickname

What is your nickname or name you prefer to be called, if any?

E-mail
*

What is your e-mail address?

Primary Phone
*

What is your primary phone number? Please format as (234) 567-8910.

Gender *

female

male

other

prefer not to answer

Birthdate
*

YYYY

Current Address
*

What is your current address, city, state, and ZIP? Please use initial capitalization.

Years
*

How many years have you lived at your current address?

Prior Address
*

What was your previous address, city, state, and ZIP? Please use initial capitalization.

Spouse/Partner

What is your spouse or partner's first and last name? Please use initial capitalization.

Emergency Contact
*

What is your emergency contact's first and last name? Please use initial capitalization.

Emergency Relation
*

What is your emergency contact's relationship to you?

Emergency E-mail
*

What is your emergency contact's e-mail address?

Emergency Phone
*

What is your emergency contact's phone number? Please format as (234) 567-8910.

Referral

How did you find out about Community Club?

Known Tutors

List the names of any Community Club tutors you know. Please use initial capitalization.

Orientation Date
*

Orientations are held on Thursdays from August through April at 6:15pm at 1313 New York Avenue NW. What date will you attend orientation? (No minimum advance notice is required; even if orientation is today, you can come to any listed here.) Please come on the date you specify; we rely on your answer here as your RSVP.

Employer *

What is the name of your employer? Please use initial capitalization.

Occupation *

What is your occupation/job-title?

License
*

Do you have a valid driver's license?

Hobbies
*

What are your hobbies?

Degrees
*

We limit volunteers to those who have graduated college. Please list all your colleges, graduate schools, majors, degrees, and years of degrees. Please use initial capitalization. (If you have not graduated college, please do not continue with this form.)

Volunteering

Please list organizations with which you volunteered during the last five years. Specify those that work with children or vulnerable adults. Please use initial capitalization.

Reference #1
*

We will contact three references of people not related to you who have known you for at least five years. Please provide the first and last name of Reference #1. Please use initial capitalization.

Reference #1 Relation
*

Please provide your relationship to Reference #1.

Reference #1 E-Mail
*

Reference #2
*

Please provide the first and last name of Reference #2. Please use initial capitalization.

Reference #2 Relation
*

Please provide your relationship to Reference #2.

Reference #2 E-mail
*

Reference #3
*

Please provide the first and last name and your relationship to Reference #3. Please use initial capitalization.

Reference #3 relation
*

Please provide your relationship to Reference #3.

Reference #3 E-mail
*

Past Concerns
*

Review the following questions:

(A) Has your driver’s license ever been restricted or suspended?

(B) Have you ever been arrested, charged, or convicted of a misdemeanor or felony (include any DUI/DWI or other adult arrest diverted by a pre-trial diversion program)?

(C) Have you ever been subject to an allegation or disciplinary action that you violated an organization’s policy on sexual misconduct?

(D) Have you used illegal drugs in the last three years? (While not an automatic disqualification, drug use is a concern as it may affect our students.)

(E) Have you ever been asked to leave a program for youth or children?

If no to all, type "no". If yes to any, type "yes" and provide an explanation.

Agreements
*

Do you agree to the following?

(1) I will abide by all Community Club rules and policies in the Tutor Handbook or as conveyed by CC leaders.
(2) If requested by my student’s parent or guardian, I will notify him or her when I plan to meet with my student at times other than Thursday nights at Study Hall.
(3) If there is an emergency in which I am unable to communicate my medical needs, I give permission for Community Club to arrange for my transport to a medical facility.
(4) I agree not to hold New York Avenue Presbyterian Church or any tutors or leaders liable for any injuries, physical or psychological, which occur during Community Club activities.
(5) I give permission for any artwork or photos created by or of me, individually or in a group, to be exhibited as a part of club activities, including the website and printed publications.
(6) I understand that all information I provide may be checked by volunteer leaders.
(7) I agree to release from liability any person or organization that provides information about me, including those I have listed as references. I indemnify and hold harmless New York Avenue Presbyterian Church, its employees, representatives, and agents from all claims or causes of action relating in any manner to the verification of information on this form.
(8) I hereby waive any right I may have to inspect any information provided about me by any person or organization I have listed on this form.

If you agree to all of the above, type "yes". If you do not agree to any, type "no" and specify which items you do not agree to.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of New York Avenue Presbyterian Church.

Does this form look suspicious? Report

Forms