Peer Tutoring Registration Form
Please fill in the form below, tutoring will be via zoom.
Full Name:
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Age:
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Date of Birth (MM/DD/YYYY)
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Peer Tutoring:
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I would like to sign up as
Tutor (12-17 yrs)
Peer (7-11 yrs)
Day(s) available to attend (Mon-Fri between 4:30-6:30 PM):
Help with English, Math, French, and/or other:
Home Address:
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Postal Code:
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Primary Phone Number:
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Area Code
Phone Number
Primary Email Address:
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Emergency Contact Full Name Name:
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Emergency Contact Phone Number:
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Area Code
Phone Number
Emergency Contact E-mail:
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Special Needs or Accommodations
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Gender: I confirm that I self identify as a women as the Jean Augustine Centre for Young Women's Empowerment designs workshops and programs specifically for women and girls.
I Agree
Attendance: Peer tutoring requires a weekly commitment for at minimum six weeks (excluding extenuating circumstances including illness, vacation, and other necessary time off). I confirm that I will participate in all registered program days. If a program day is missed (without notice given to J.A.C.) then you may be removed from the program, not receive certification and future participation in programs may be affected.
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I Agree
Photography and Video Release: I give permission for J.A.C. to capture photography of myself during programs for potential use in future promotional materials. I give permission for J.A.C. to record online program content that may feature myself for potential future operational or program material.
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Yes
No
I have read and understand the information presented in this form. I agree to cooperate with all J.A.C. procedures and regulations. Signature
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Clear
Would you like to be contacted via text messages about J.A.C.'s programs, workshops, and events?
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Yes
No
Submit Form
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