RtS Student Enrollment Form

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I,  Q1. First Name Last Name the q2.  ( male female ) student , would like to register for  tutoring Q3. YES     NO , and I prefer  Q4. In-Person     Virtual     Whichever is cheaper & quicker to get started             Tutoring.

For minor Students under the age of 18, define the guardian(s). OR if older than 18 but the guardian is responsible for payment:
Q5. Age of Student:    Number
Q6. Under 18    YES     NO
Q7. Over 18 but payments by “guardian”?
YES     NO
If questions 6 or 7 is YES, Please provide…
Q8. Parent/Guardian Name:    First Name     Last Name
Q9. Parent/Guardian Relationship:    Type a label
Q10. Parent/Guardian Phone #:    Area Code     Phone Number
Q11. Parent/Guardian Email Address:    Email
Q12. if doing virtual tutoring, must provide Students phone number as well. May need this anyways:
Area Code     Phone Number

Q13. Grade of Student education (note that college freshman = grade 13, Sophomore= 14, Etc:    <21
Q14. Name of School Attending:
Q15. Name of Class(es) in Subject(s) seeking tutoring (EX: Grade 4 Math, Algebra I, AP Chemistry, or Mechanical Engineering 403, )

I am interested in tutoring in the subjects of
• Q16. Science            ,
• Q17 Technology   ,
• Q18 Engineering , • HS Engineering Concepts (Advanced Notice required )     • CHEMICAL ENGINEERING FIELD; Sub-genres & classes up to graduate level:     • CIVIL ENGINEERING FIELD; Sub-genres & Classes up to graduate level:     • ELECTRICAL ENGINEERING FIELD; Sub-genres & Classes up to graduate level:     • MECHANICAL ENGINEERING FIELD; Sub-genres & Classes up to graduate level:     • INTERDISCIPLINARY up to graduate level: ,
• Q19. Math       And/Or
• Q20. COLLEGE/TEST PREPARATION TUTORING
for the upcoming semester.
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Email
example@example.com
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The student, or their guardian if the student is a minor, qualifies for the following discounts
10% homeschool family discount
10% Veterans discount
Student would be the first generation of college student or degree holders in the family (qualifies for 2-months free SAT/ACT preparation)
5% Virtual Learning Discount
Student is recipient of Virtual Learning Tech 2 Students Grant of a computer or home WiFi and minimum 3 months free enrollment in tutoring.
Referral Total savings = $150: Ask for Refferal code to get $100 in free tutoring when you refer someone who signs up for minimum $100 and/or 2 - months in tutoring — person you refer also gets $50 off services for being referred
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Root to STEM ‘s nonprofit tutoring model was designed so that prices started off lower than their for-profit competitors — $60/hr for 1-on-1 tutoring before any discounts are applied. In addition, 75% of people then qualify for either 25%, 50%, 75%, or 100% off in need/income-based financial-aid — thanks to our ultra-low-bar to qualifying for assistance. 25% of people qualify for 100% financial-aid (free-services)    Wish to apply for need based Learning Technologies Grant/Long-Term 0% interest loan under Root to STEM’s T2S & STEMming the Digital Divide grant program

I      wish to apply for need based financial aid.
YES     NO
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If applying for Financial Aid, Continue Below…
SECTION 1 - STUDENT INFORMATION:

What is the highest school parent 1 completed?

What is the highest school parent 2 completed?
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SECTION 2 - STUDENT DEPENDENCY STATUS: 2A ) IF You can check ANY of the following boxes, you will not have to provide parental information. Skip to Section 4. 2B) IF you check NONE of the following boxes, you will be asked to provide parental information. Go to the next page.
I was born before January 1, 1998
I am serving on active duty in the U.S. Armed Forces
Since I turned age 13, both of my parents were deceased
I was a dependent or ward of the court since turning age 13
I am married
I am a veteran of the U.S. Armed Forces
I was in foster care since turning age 13
I am currently or I was an emancipated minor
I will be working on a master’s or doctorate program (e.g., MA, MBA, MD, JD, PhD, EdD, graduate certificate)
I now have or will have children for whom I will provide more than half of their support between July 1, 2021 and June 30, 2022
I have dependents (other than children or my spouse) who live with me and I provide more than half of their support
I am homeless or I am at risk of being homeless
I am currently or I was in legal guardianship
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If Applying for Financial Aid, Continue Below…

SECTION 3: PARENT INFORMATION —
“Who is considered a parent? “Parent” refers to a biological or adoptive parent or a person determined by the state to be a parent (for example, if the parent is listed on the birth certificate). Grandparents, foster parents, legal guardians, older siblings, and uncles or aunts are not considered parents on this form unless they have legally adopted you. If your legal parents are living and married to each other, answer the questions about both of them. If your legal parents are not married and live together, answer the questions about both of them. In case of divorce or separation, give information about the parent you lived with most in the last 12 months. If you did not live with one parent more than the other, give information about the parent who provided you the most financial support during the last 12 months or during the most recent year you received support. If your divorced or widowed parent has remarried, also provide information about your stepparent”

3Ai) Parent 1 Name:    First Name     Last Name
3Bi) Parent 2 Name:    First Name     Last Name
3Aii) Parent 1 S.S.#/Tax ID:    ###-##-####
3Bii) Parent 2 S.S.#/Tax ID:    ###-##-####
3Aiii) Parent 1 Date of Birth:    Date
3Biii) Parent 2 D.o.B.:    Date
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• 3C) What was your parents’ adjusted gross income for 2019? Skip this question if your parents did not file taxes. Adjusted gross income is on IRS Form 1040—line 8b ___    In dollars $

3D) The following questions ask about earnings (wages, salaries, tips, etc.) in 2019. Answer the questions whether or not a tax return was filed. This information may be on
the W2 forms or on IRS 1040—line 1
+ Schedule 1—lines 3 + 6
+ Schedule K-1 (IRS Form 1065)—Box 14 (Code A).

• 3Di) Parent 1 (mother/father/stepparent) made $ Total earning all sources, including above
• 3Dii) Parent 2 (mother/father/stepparent) made $ Total earning all sources, including above

• 3E) In 2019 or 2020, did anyone in your parents’ household receive: (Check all that apply.)    Medicaid     Free or Reduced Price School Lunch     Supplemental Security Income (SSI)     Temporary Assistance for Needy Families (TANF)     Supplemental Nutrition Assistance Program (SNAP)     Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
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3F) Did your parents have any of the following items in 2019? Check all that apply. Once online, you may be asked to report amounts paid or received by your parents.
3Fi) Additional Financial Information:
American Opportunity Tax Credit or Lifetime Learning Tax Credit     Child support paid     Taxable earnings from work-study, assistantships or fellowships     Taxable earnings from work-study, assistantships or fellowships     Combat pay or special combat pay     Cooperative education program earnings

3Fii) Untaxed Income:
• Payments to tax-deferred pension and retirement savings plans     • Housing, food and other living allowances paid to members of the military, clergy and others     • IRA deductions and payments to selfemployed SEP, SIMPLE and Keogh     • Child support received     • Veterans noneducation benefits     • Tax exempt interest income     • Other untaxed income not reported, such as workers’ compensation or disability benefits     • Untaxed portions of IRA distributions and pensions
**         Your parents may be asked to provide more information about their assets. Your parents may need to report the net worth of their current businesses and/or investment farms.
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SECTION 4 — STUDENT INFORMATION (fill out this instead of section 3 if you checked one of the boxes from Section 2 - Student Dependency Status)

4A) What was your (and spouse’s) adjusted gross income for 2019? Skip this question if you or your spouse did not file taxes. Adjusted gross income is on IRS Form 1040—line 8b. $ Combines income in Dollars

4B) The following questions ask about earnings (wages, salaries, tips, etc.) in 2019. Answer the questions whether or not a tax return was filed. This information may be on:
the W2 forms or
on IRS 1040—line 1
+ Schedule 1—lines 3 + 6
+ Schedule K-1 (IRS Form 1065)—Box 14 (Code A).
• 4Bi) How much did you earn from working in 2019? $ Total earning all sources, including above

• 4Bii) How much did your spouse earn from working in 2019? $
Total earning all sources, including above
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• 4C) In 2019 or 2020, did anyone in your household receive: (Check all that apply.)

Medicaid,     Free or Reduced Price School Lunch,        Supplemental Security Income (SSI),     Temporary Assistance for Needy Families (TANF),     Supplemental Nutrition Assistance Program (SNAP),     Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

•4D) Did you or your spouse have any of the following items in 2019? Check all that apply. Once online, you may be asked to report amounts paid or received by you or your spouse.
4Di) ADDITIONAL FINANCIAL INFORMATION
-American Opportunity Tax Credit or Lifetime Learning Tax Credit,
-Child support paid                                   -Taxable earnings from work-study, assistantships or fellowships,     -Taxable college grant and scholarship aid reported to the IRS as income     -Combat pay or special combat pay,     -Cooperative education program earnings

4Dii) Untaxed Income:
• Payments to tax-deferred pension and retirement savings plans     • Housing, food and other living allowances paid to members of the military, clergy and others
• IRA deductions and payments to selfemployed SEP, SIMPLE and Keogh     • Child support received     • Veterans noneducation benefits     • Tax exempt interest income     • Other untaxed income not reported, such as workers’ compensation or disability benefits     • Untaxed portions of IRA distributions and pensions

**        Your may be asked to provide more information about their assets. You may need to report the net worth of their current businesses and/or investment farms.
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Additional Comments or Questions
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