Home Address (street, city, state, zip)
Emergency Contact and Phone Number
List any allergies/medications/or special needs
Child's Current School
Child's Grade Level
First Grade (1st)
Second Grade (2nd)
Third Grade (3rd)
Fourth Grade (4th)
Fifth Grade (5th)
In what academic area(s) does your child help? Please explain.
What is your child's reading level? (Please skip if your child does not need help in reading/literacy/English Language Arts.)
Do Not Know
Is your child an English Language Learner? (Is English a second language?)
What primary language is spoken at home?
Does your child have an IEP?
Does your child receive any pull-out or interventions services, not including special education? (please explain)
Please read the following terms and conditions:1) I understand that this is not a drop off program and I must remain onsite with my child in the presence of the tutor at all times. 2) I understand that the Tutoring services provided by Fellowship Baptist Church are a ministry of the church, and materials used may reflect the beliefs of the church. I fully accept the conditions and hold harmless from any legal liability Fellowship Baptist Church and any persons involved in the tutoring ministry. 3) In the event of an emergency that requires medical treatment for the above named child(ren), I understand every effort will be made to contact me or my emergency contact. However, if I/we cannot be reached, I give permission to the Fellowship Baptist Tutoring Ministry Volunteers to secure the services of a licensed physician to provide care necessary for my child(ren)’s well-being. I assume responsibility for all costs connected to any accident or treatment of my child.
Please type your name for a signature.
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