Child Information
Child Name
*
Child First Name
Child Last Name
Preferred Name (if child has one)
Gender
*
Female
Male
Birthdate
*
-
Month
-
Day
Year
Date
Current Grade
*
1st
2nd
3rd
4th
5th
School Name
*
What program(s) would you like your child to be a part of?
*
1st-2nd Grade: Reading Club
3rd-5th Grade: SPARK
3rd-5th: Add to Waitlist for Virtual Tutoring
1st-2nd Grade: SPARK - Coming 2/6/2022
Child's T-shirt Size
*
S
M
L
XL
Parent/Guardian Information
Parent/Guardian Name
*
Parent/Guardian First Name
Parent/Guardian Last Name
Relationship to child
*
Parent
Legal Guardian
Other
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent Phone Number
*
-
Area Code
Phone Number
Parent Email
example@example.com
What time zone are you in?
Pacific Standard Time
Mountain Standard Time
Central Standard Time
Eastern Standard Time
Hawaii-Aleutian Standard Time
Alaska Standard Time
Other
How did you hear about Impact?
Table at school
Facebook
Flyer
Family/Friends
Other
If you would like to have an initial 20-minute meeting with the tutor, please indicate your availability
Mondays @ 5:30pm
Tuesdays @ 5:30pm
Wednesdays @ 5:30pm
Thursdays @ 5:30pm
No meeting needed
Other
Other Information
Impact's vision is to provide academic support for underserved communities.
Annual Household Income
*
Below $40,000
$40,001 - $50,000
$50,001 - $60,000
$60,001 - $70,000
Above $70,000
Decline to state
Select all of the following that apply:
My child attends a Title 1 school
My child receives a free or reduced-price lunch at school
My family qualifies for food stamps
None of the above
Primary Language spoken in the home (if NOT English)
Questions?
Please add any questions or comments:
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