Student Information Collection Form
General Information
Student Name
First Name
Middle Name
Last Name
Parent/Guardian Email
example@example.com
Phone Number
Please enter a valid phone number.
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Ethnicity
Please Select
Prefer Not To Answer
African American
Hispanic/ Latino
Asian
Caucasian
Native American/ Alaskan
Hawaiian/ Pacific Islander
Middle Eastern
Other
Gender
Please Select
Prefer Not To Answer
Female
Male
Gender Neutral
Other
Does your child have any allergies? If yes, please list.
Grade
Does your child receive Special Education services or 504 accommodations?
*
Back
Next
Residence Information
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/ Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
School Information
School Name
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
MH
Notes
Saturday Session Availability (other session times may be arranged)
*
Other
Other pertinent information about your child...
Signature
Submission of this form indicates agreement to literacy tutoring by GLS for the duration of the 2023-24 School Year. I understand that these services are one day weekly in 40 minute increments. To receive these services, I understand that I must have already obtained proof of eligibility from Arkansas Department of Education, DESE, and am able to produce said proof. Further, in the case that DESE does not honor its financial obligation, I agree to pay half of the total amount due by the end of the contracted period.
*
I agree
Submit
Should be Empty: