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Please fill out the form below to take the first step toward being successful in school.
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Student's Full Name
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Date of Birth
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Email (Student)
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Email (Parent)
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Street Address
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Town
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State, Zip Code
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Cell Phone Number (Parent)
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Home Phone Number (Parent)
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Cell Phone number (Student)
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Name of the School Student Attends
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GRADE ENTERING IN SEPTEMBER
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Grade 4
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Other:
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Do you receive free or reduced price school lunch?
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Services Interested In (September -June)
Monday-Friday 3:30pm- 5:30pm
Saturday 10:00am-12:00pm
Tutoring- Math
Tutoring - English
Tutoring - Other Academic Subjects
Test Prep (PSAT/SAT/ACT/ACCUPLACER)
Monday-Friday 3:30pm- 5:30pm
Saturday 10:00am-12:00pm
Tutoring- Math
Tutoring - English
Tutoring - Other Academic Subjects
Test Prep (PSAT/SAT/ACT/ACCUPLACER)
Services Interested In (September -June)
Friday 4:30pm- 5:30pm
Girls for STEM
Friday 4:30pm- 5:30pm
Girls for STEM
Where did you hear about this program?
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By submitting this form I confirm that I am at least 18 years of age, and provide my written consent for Million Reasons to contact me/my child using email or telephone and provide academic enrichment services to my child/children. I understand that only those receiving free or reduce price school lunch is eligible to receive the free services of Million Reasons and that I have to send the appropriate documents to Million Reasons to be accepted to the free programs.
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Name of Parent/Guardian:
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Parent's Signature
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Date
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