Tutoring and Mentoring

Students General Information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Birthdate

Gender

Medical Concerns/Allergies/Medications

Parent/Guardian Information (Primary Contact)

First Name

Last Name

Email

Contact Number

Relationship to Student

Parent/Guardian Information

First Name

Last Name

Email

Contact Number

Relationship to Student

I authorize this individual to pick up my child.

Yes

No

Emergency Contact Information

First Name

Last Name

Email

Contact Number

Relationship to Student

I authorize this individual to pick up my child.

Yes

No

Students Academic Information

School

Grade

Does your student have an IEP or 504 plan with their school

Yes

No

If yes, please elaborate.

In what areas/subjects does your student excel?

What areas could does your student struggle?

Anything else you'd like to share?

Teacher Information

Teachers First Name

Teachers Last Name

Email

Phone Number

Photography Waver

By selecting "I approve" below, I hereby give permission for First Lutheran Church, and its designees to utilize photographs taken of me for the purposes of publicity on web sites, newsletters, brochures, or other media. I understand that such photographs are the sole property of First Lutheran and its designees to use as needed for stated purposes. Further, I relinquish any right to compensation for their use.

I approve

I decline

Final Verification and Submission

I verify that all the provided information is correct, and acknowledge that by submitting this form I am signing my child up to attend The Success Center: Tutoring and Mentoring.

Check here to verify

Tutoring and Mentoring