Tutoring Application
Child's Name
Your answer
Child's Birthday
MM
/
DD
/
YYYY
Parent/Guardian Name(s)
Your answer
Home Address (street, city, state, zip)
Your answer
Phone number(s)
Your answer
Email Address
Your answer
Emergency Contact and Phone Number
Your answer
List any allergies/medications/or special needs
Your answer
Child's Current School
Your answer
Child's Grade Level
In what academic area(s) does your child help? Please explain.
Your answer
What is your child's reading level? (Please skip if your child does not need help in reading/literacy/English Language Arts.)
Is your child an English Language Learner? (Is English a second language?)
What primary language is spoken at home?
Your answer
Does your child have an IEP?
Does your child receive any pull-out or interventions services, not including special education? (please explain)
Your answer
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.
Your answer
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