Tutor Request Form

WIW/GTT Application for One on One Tutoring

Request tutoring services by filling out the form completely
Student's Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
E-mail*
Type of Tutoring*
Please list the Full Name(s) & Phone Number(s) of ALL individuals who have permission to pick up your child. If their name is not on this list, we will not be able release your child to them*
Subject for Tutoring*
Grade*
Reading Grade Level (if requesting reading tutoring)
Math Grade Level/Subject (requesting tutoring for)
What School Does Your Child Attend?*
Details of Their Tutoring Needs*
County You Live In*
Parent(s)/Guardian(s) Contact Information
Parent/Guardian Name #1*

First NameLast Name
E-mail (this is how we communicate so please make sure it is accurate)*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographics

Please Complete Fully. Your Decision Will Not Be Based On These Factors. This Is For Funding Purposes Only.
Age:*

18-2425-3435-4445-5455-6465-7475 or older
Please Specify Your Ethnicity:*

WhiteBlack or African AmericanHispanic or LatinoAsian/Pacific IslanderNative American or American IndianOther
Martial Status:*

Single, never MarriedMarried or Domestic PartnershipWidowedDivorcedSeparated
Are you currently:*

Employed for WagesSelf-EmployedOut of Work & Looking For WorkOur of Work but Not Currently Looking For WorkA HomemakerA StudentMilitaryRetiredUnable to Work
Highest Level of Education You Have Completed:*

No Schooling CompletedSome High School, no DiplomaHigh School Graduate, Diploma or the Equivalent (for example: GED)Some College, no DegreeTrade/Technical/Vocational TrainingAssociate DegreeBachelor's DegreeMaster's DegreeProfessional DegreeDoctorate Degree
Household Income:*

>$15,000$15,000 - $24,999$25,000 - $34,999$35,000 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000 - $149,999$150,000 - $199,999$200,000+
Emergency Contact

Please complete Name, Address, & Phone Number
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Does your child have ANY allergies or health conditions?*
Every 9 weeks there will be a parent evaluation form. If you do not complete the evaluation form, the student will be released from the tutoring program. PLEASE CHOOSE ONLY ONE.*

By checking this box, I acknowledge that I have read and accept the terms.By checking this box, I acknowledge that I have read and I do not accept the terms. (This will influence the decision of your application)
I give my permission to WIW/GTT to use my child’s photo, video, sound recording and first name. This information may be shared on our Social Media accounts & other outlets only for the benefit of the program.*

YesNo
By signing this form I give my permission for my child to participate in the impact reading tutoring program provided by Women Inspiring Women nonprofit organization. I understand transportation WILL NOT be provided and that my child will need to be there on time and picked up on time, if in-person.
- I understand that WIW is offering Impact Reading Tutoring Program, with a minimal charge to me and it is intended to support my child’s reading challenges and goals.
- I agree NOT to hold responsible, Women Inspiring Women (WIW), teachers, tutors, volunteers, nor any Women Inspiring Women volunteers, staff, or any of person.
- WIW is not guaranteeing your child will be at grade reading level after the completion of the program, but they can stay in the program as long as progress is being made.
- WIW or none of the titles listed above will be held responsible if failure to achieve any stated or unstated academic or person goal, standard, or achievement.
- Women Inspiring Women has the right to stop this impact reading program at anytime that deem necessary, such as lack of funds, or not enough volunteers for the program.
- Your child is responsible for attending all regular scheduled days that are scheduled zoom or in person.
- If my child fails to attend via zoom or in person one or more scheduled tutoring sessions (NO SHOW) as determined by the intake information this may result in the removal of the child from the program.
- Students are expected to contribute to a positive, healthy, and non-disruptive learning environment. Disruption, excessive noise, cell phone usage, and vulgar, inappropriate, discriminatory, or profane language are not tolerated.
- I agree and understand that if you feel that my child need more help than what your program can give, after we discuss the reason, I understand they will be dismissed.
- IF IN PERSON, NO ONE WILL BE PERMITTED TO PICK UP YOUR CHILD IF THEIR NAME IS NOT LISTED. MAKE SURE YOU LIST ALL ADULTS EVEN IF YOU RESIDE IN THE SAME HOUSEHOLD.
Signature Of Parent/Guardian*

Clear
If you would like to make a donation or help out in any other way, please contact us by phone or email at:

256-469-8163

info@womenflourishingtogether.org

Ways to donate:

Our Website: www.womenflourishingtogether.org

Cash App: $womeninspiringwomen

Check by Mail: Women Inspiring Women

1629 4th Ave SE Ste 130

Decatur, AL 35601
Should be Empty:

WIW/GTT Application for One on One Tutoring

Parent(s)/Guardian(s) Contact Information

Demographics

Emergency Contact