Family Learner Intake Form

LITERACY CENTRAL VANCOUVER ISLAND

Family Learner Intake Form
Family Learner Intake Form
NAME OF LEARNER(S):
First and Last Name
Birth date

MonthDayYear
Date
First and Last Name
Birth date

MonthDayYear
Date
First and Last Name
Birth date

MonthDayYear
Date
NAME OF PARENTS/GUARDIANS(S):
Parent / Guardian First and Last Name
Parent / Guardian First and Last Name
Child learner(s) accompanied by
Relationship to learner(s)
ADDRESS
Street
City
Postal Code
CONTACT DETAILS
Phone
Email
example@example.com
EMERGENCY CONTACT
Name
Phone
ANCESTRY
If you are new to Canada what is your legal status in Canada
How many years have you been living in Canada
EDUCATIONAL BACKGROUND
School Name
Grade (if multiple learners please list all grades)
To date, please describe the academic support provided to the learner?
EDUCATION (IF APPLICABLE)
Is/Are the learner(s) homeschooled?

YesNo
For how many years has the learner(s) been homeschooled?
Name of program or online school
ADDITIONAL INFORMATION
How is the learner's vision?
Hearing?
Do words, letters, numbers ever move?

YesNo
Are there any medical or physical conditions that we should know about that might interfere with your learning?
LITERACY/ ESL
Please check off the area(s) where you would like support:

SpellingGrammarReading ComprehensionPhrasing & ExpressionBlending soundsDiphthongsReading AloudReading FluencyLong Vowel SoundsShort Vowel SoundsLetter RecognitionPhoneme AwarenessDecoding / AccuracySyllabicationSegmentationPunctuationSentence / Essay WritingESL"Reading Buddy"Homework CompletionOther
Based on your above selection, can you select 3-5 items the learners find the most challenging? Please explain
What strategies does the learner use when they come across a word they don't know?
What is your literacy goal for the learner?
NUMERACY
Please check off the areas where you would like help with:

Place ValueAdditionDivisionBudgetingGeometryCountingSubtractionFunctionsHomework CompletionWord ProblemsBankingFractionsPercentages / RatioGraphingCalculusAlgebraFinancial LiteracyNumber SenseMultiplicationDecimalsHandling MoneyMeasurementStatisticsTime TablesProbability
Based on your above selection, can you select 3-5 items the learners find the most challenging? Please explain
What strategies does the learner use when they come across a word they don't know?
What is your numeracy goal for the learner?
AVAILABILITY
Is there anything that could interfere with your ability to meet with your tutor? If yes, please explain.

YesNoOther
What days are best to meet with a tutor?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What times work best to meet with a tutor?

Morning (9am - 12pm)Afternoon (12pm - 5pm)Evening (5pm - 8pm)Other
Where works best to meet with a tutor?

LCVI (19 Commercial Street)OnlineOther
PARENT / GUARDIAN CONSENT FORM

Sharing of Assessment Information with Tutor
Literacy Central Vancouver Island (LCVI) provides literacy, ESL and numeracy assessmentsfor our learners. The literacy, ESL and numeracy assessments completed by learners arenot used for diagnosis. The assessments provide LCVI with a general knowledge of theliteracy/ESL/numeracy area(s) the learner(s) may require extra support. This information isthen used by the Tutor Coordinator to pair LCVI learners with a tutor they feel will bestmeet the needs of the learner(s). A copy of the assessment results would also be providedto the tutor for the purpose of planning and preparation; setting short and long termgoals for the learner(s).I First Name Last Name (Parent/Guardian) understand that Literacy CentralVancouver Island will be conducting a Type a label (literacy/ESL/numeracy) assessment with First Name Last Name (learner name) First Name Last Name (learner name) First Name Last Name (learner name). I understand that a copy of the assessment results will be used for pairing the learner(s)with a tutor.

I consent to Literacy Central Vancouver Island sharing a copy of the assessment results with the tutor for the purpose of planning and preparation; setting short and long term goals for the learner(s).
Signature

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LEARNER AGREEMENT
By enrolling in the Family one-to-one Tutoring Program, I agree to the following:
- I agree to attend and participate in the Family Tutoring Program with my child/children.
- I will come to my tutoring sessions as scheduled and on time.
- If I cannot attend, I will call my tutor ahead of time (the day before, if possible).
- If I am unhappy with my tutor or my lessons, I will let the Tutor Coordinator know so that other arrangements can be made (call 250.754.8988).
- If I decide to stop tutoring, I will let both my tutor and the Tutor Coordinator know as soon as possible (call 250.754.8988)
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LITERACY CENTRAL VANCOUVER ISLAND

Family Learner Intake Form

NAME OF LEARNER(S):

NAME OF PARENTS/GUARDIANS(S):

ADDRESS

CONTACT DETAILS

EMERGENCY CONTACT

ANCESTRY

EDUCATIONAL BACKGROUND

EDUCATION (IF APPLICABLE)

ADDITIONAL INFORMATION

LITERACY/ ESL

NUMERACY

AVAILABILITY

PARENT / GUARDIAN CONSENT FORM

LEARNER AGREEMENT