ACCAPALS Parent & Child Intake Questionnaire

ACCAPALS Parent & Youth Intake Questionnaire
ACCAPALS Parent Intake Questionnaire and Registration

The Afro Canadian Caribbean Association "ACCAPALS" Youth Tutoring/Mentoring Program aims to help BIPOC youth in Hamilton to develop a positive relationship with school and develop resilience to succed in life. It will focus on building important skills for school and future career planning.

The "ACCAPALS" Youth Tutoring/Mentoring program will be connecting children ages 7-16 with a tutor/mentor "ACCAPAL" to support the with their academics. The youth and tutor/mentor will engage in minimum of 1 hour weekly (1on1) sessions. To note, apart of this program we will have a drop-in hours after school at our main office 423 king st E for youth members during the week.

If this program, sounds of interest to you/your child, please fill the form below. If you have any questions or concerns, please reach out to the youth program coordinator.

Jarek Richards

PH: 905-385-0925 Email: accayouthprogramcoordinator@gmail.com

The information you provide will help us find the best match with an ACCAPAL Tutor/Mentor and will also allow us to tailor the tutoring and mentoring to the unique strengths and needs of each child.
Administrative Information
Youth Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Gender*
School Name*
Grade*
Which Age group does your child belong to*

Elementary 8-12 years oldMiddle School 13-15 years oldHigh-School 16-18 years old
3. Student Email? if applicable
example@example.com
Parent Information
Name*

First nameLast name
Phone #*
Parent email address*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Province*
Postal code*
Emergency Contact Information
Name*

First NameLast Name
Email address
example@example.com
Primary phone number*
Relationship to student*
General Overview of Your Child

Provide some general comments on your child. If you cannot answer any questions, or do not feel comfortable please leave it blank
1. What are some positive things you can say about his/her personality?
2. What are some of his/her favourite activities (hobbies, games, sports, video games, etc.)?
3. What are his/her favourite books (this can include books he/she likes to read or books that are read to him or her)?
4. What are his/her favourite TV shows, movies, YouTube videos, etc.?
5. Is your child currently experiencing any challenges either at home or school? If yes, please explain.
6. Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide brief details.
7. Is your child willing to attend an initial training session ?
Reading, Schooling, & Education

This section is concerned with your child's experience with school and learning in general, including subjects he or she likes and dislikes as well as his/her reading skills.
1. What school subjects does he/she like best or performs well in?*
2. What school subjects does he/she dislike or have particular problems with?*
3. Do you use or recommend any techniques to keep your child focused and actively engaged in reading and the tutoring session generally (e.g., incentives, frequent breaks, praise, etc?
4. Describe your child's school attendance and behavior performance.
5. What subject do you wish your child to be tutored?*
Given the child's age and grade level, how would you rate his/her reading abilities? (Please check the most appropriate box below)*

Excellent: (reads well above grade level, pronounces all words, comprehends everythingGood: (reads a little above grade level, pronounces most words, comprehends most things read)Satisfactory: (reads at grade level, has some trouble pronouncing words, has some troubles comprehending what was read)Poor: (reads below grade level, has trouble pronouncing most words, has trouble comprehending what was read)Very poor: (reads well below grade level, cannot pronounce most words, does not comprehend what was read)
Cognitive & Medical Information

Information on any cognitive, psychological or behavioural issues we should be aware of.
1. Has this child been diagnosed with any learning disabilities (e.g., dyslexia), psychological issues (e.g., ADD, ADHD etc, or medical conditions that may affect his/her learning and behaviour?
2. Does your child have any behavioural issues that we should be particularly aware of?
3. Do you use or recommend any specific remedies that work well in dealing with the child's learning disabilities, psychological challenges, or problem behaviours?
4. Can you provide any additional background information that may be helpful to Afro Canadian Caribbean Association ACCAPALS Youth Mentorship/Tutoring Program in matching your son/daughter with an appropriate mentor?
5. Does your child have any physical challenges/mobility challenges or limitations?
6. Is he/she/they currently on any type of medication? If so, please specify.
7. Does your child have any known allergies or adverse reactions to medications or food? If yes, please describe them below*
Name of Primary Care Physician

First NameLast Name
Physician Telephone No
The Afro Canadian Caribbean Association ACCAPALS Youth Mentoring/Tutoring Program appreciates you and your child's interest in becoming a mentee. This application is intended as a means of informing and gaining the consent of a parent/guardian to allow their child to participate in the ACCAPALS Tutoring/Mentoring Program.

After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the mentoring program.

Much of the information you supply in this application will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian and mentor based first upon anonymous information provided about each other.
Please check each of the following*

I give my informed consent and permission for my child to participate in the Afro Canadian Caribbean Association ACCAPALS Youth Mentoring/Tutoring Program and its related activities.
I agree to have my child follow all mentoring program guidelines and understand that any violation on my child's part may result in suspension and/or termination of the mentoring relationship.
I hereby acknowledge that my child will be transported by his/her/they /them mentor and/or Afro Canadian Caribbean Association Mentorship representatives while participating in the ACCAPALS Youth Mentoring/Tutoring Program, and that such transportation is voluntary and at his/her/they/them own risk.
I release the ACCAPALS Youth Mentoring/Tutoring Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her/they/them participation in the program, including but not limited to transportation, and hold harmless any Afro Canadian Caribbean Association program or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
(optional) I agree to allow the ACCAPALS Youth Mentoring/Tutoring Program to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
I have read, understood, and completed the above form. Having been briefed regarding the nature of the ACCAPALS Youth Tutoring/Mentoring program through ACCA, I authorize my child to attend and participate the program.
Parent signature*

Clear
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
ACCAPALS Parent Intake Questionnaire and Registration

*To be completed by the mentee "read and sign below"

By choosing to participate in the Afro Canadian Caribbean Association ACCAPALS Youth Tutoring/Mentorship Program I agree to:

Follow all rules and guidelines outlined by the program coordinator and have a positive attitude and be respectful of my mentors and staff involved.

Make a one-year commitment with my mentor meet at least once a month with my mentor and weekly contact with my mentor.

Obtain parent/guardian's permission for all meeting times at least 24-48hrs in advance.

Be on time for scheduled meetings or call my mentor at least 24 hours beforehand if I am unable to make a meeting.

Discuss monthly meeting times and activities with the program coordinator and openly communicate with the program coordinator as requested.

Inform the program coordinator of any difficulties or areas of concern that may arise in the relationship.

Notify the program coordinator if I have any changes in address or phone number.

Attend in-service mentee training sessions/group activities when opportunities arise atleast a minimum of twice per year.
Dated*

MonthDayYear
Date
Mentee Signature*

Clear
Should be Empty:

ACCAPALS Parent & Youth Intake Questionnaire

Administrative Information

Parent Information

Emergency Contact Information

General Overview of Your Child

Reading, Schooling, & Education

Cognitive & Medical Information