WHAT: Please outline your students' academic problems/concerns and what you feel their needs are for academic support in the following box:

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WHAT grade is your student in?

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WHEN: When would you like to begin solving your academic concerns for your students?

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WHERE: Where is the best location to implement academic support/a tutoring plan?

Examples: In-Home, Local Library, Local Community Center, In-School, etc.

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WHY: Why is it important to gain help soon?

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HOW: How do you see academic support being implemented?

Examples: during school, after school, one on one, small groups, large groups, with siblings, etc.

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Do you have any questions you'd like us to address?

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Students' School District:

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Contact/Parent Name:

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Contact/Parent Phone Number:

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Contact/Parent Email Address:

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City, State and Zip Code:

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Are you interested in beginning tutoring for your student?

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How did you hear about Literacy in the Community Tutoring?

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