2023-2024 SHINE Interest Form
Thank you for your interest in SHINE's after school program! Please fill out one form PER STUDENT. Incomplete forms will not be reviewed. Once we receive this form, we will reach out to your student's school for behavior and educational records and will be in touch with you. If recommended by the school, you will then be required to complete the SHINE enrollment packet . If you have any questions regarding this form please contact Carrie Jackson at 570-408-3326 or 570-417-1343
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Student Name *
Grade *
School your child attends *
Parent Name *
Parent Phone Number *
Is the phone number you provided a cell or landline? *
Parent Email *
Address *
Student's math teacher. If you don't know, type "unknown" *
Does your child express interest in the need for homework help, STEAM subject areas, yoga, group exercise classes, art classes, and/or Spanish classes? Students do not have to participate in all classes. If no, your application will not be reviewed. *
Does the student receive free/reduced lunch? *
Has the student been suspended or expelled in the past? *
Is the student designated as ESL? *
Does the student exhibit the need for English language translation services? *
Does the student's FAMILY exhibit the need for English language translation services? *
Student exhibits weakness in: *
The student is enrolled in: *
List specific skills the student needs to work on *
List a goal you would like to see the student complete *
Briefly describe how this student could benefit most from SHINE *
Comments or extenuating circumstances staff needs to be aware of *
By typing your name in the box below allow SHINE/Wilkes University to contact your child's school and receive their behavior and educational records. *
Today's Date *
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