2024-2025 TLC Tutoring Program

Shared Information Consent
This authorizes Teton Literacy Center and Teton County School District #1 to share written or verbal information regarding my child’s academic performance, diagnosis, history, including medication, progress, psychological and educational testing, medical and legal information, social welfare and rehabilitation, reports and other materials that are relevant to my child's care. I give my permission for the staff of Teton Literacy Center, this 21st CCLC program with services located at Teton Literacy Center, Munger Elementary School, and Jackson Hole Middle School to review my child’s academic and behavior progress reports or their report card in order to document growth and progress in my child during his/her time in this before/after school or summer program. This includes attendance, academic performance, teacher surveys and information about whether my child has an identified exceptionality, an Individual Education Plan or Academic Improvement Plan, and suggestions from my child’s teacher(s) on how my child can best be helped in the program. TLC will send Wyoming Department of Education grade reports from your child’s teacher using WISERID numbers where data will be aggregated at the state level to protect your child’s identification. This data is collected to evaluate the effectiveness of TLC programs.

I understand that my records are protected under the laws regarding confidentiality, and cannot be disclosed without written consent, except in specific situations. This consent is valid throughout my child receiving services at Teton Literacy Center.
Signature*

Clear

Family Information
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Language Spoken at Home*

EnglishSpanishBothOther
In what language(s) would you prefer to receive communications from Teton Literacy Center? (These include newsletters, text messages, phone calls and letters home)*

EnglishSpanishEitherOther
1st Parent/Guardian Name*

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Relationship to Child*
Parent/Guardian Employment Status*
Parent/Guardian Work-Company Name
Home Phone*
Please enter a valid phone number.
Work Phone*
Please enter a valid phone number.
2nd Parent/Guardian Name

First NameLast Name
Relationship to Child
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
2nd Parent/Guardian Employment Status
Sibling Names and Grades

Family History

The following information is used to help us design culturally responsive programs for our students. We ask these questions in hopes to get to know your student, and your family, better and build a community where all families feel seen, heard, and belong. We appreciate your honesty.
What is your current family structure?

Mother and FatherSingle Parent/GuardianExtended Family (Grandparent(s), aunt, uncle, cousin)Two FathersTwo MothersTwo Separate HouseholdsFoster FamilyOther
What holidays does your family celebrate? Please describe.

Policies and Procedures
This Teton Literacy Program is funded through 21st Century Community Learning Centers funding, which is a FREE PROGRAM for students that could benefit from a variety of stimulating personal enrichment activities that promote school success and well-being in a safe environment. Active attendance and engagement are essential to the student and program’s success. I understand that the requirements of the program include the following:
- Failure to maintain attendance standards may result in termination from the program.
- Parents/guardians are required to notify the program if a youth will be absent and/or prior to withdrawal from the program.
- Youth will maintain a consistent weekly attendance and may not have more than 2 unexcused absences. Parents or student must call to inform staff in advance if they will not be attending that day (307-733-9242).
- Youth will participate in programming activities with an emphasis on literacy skills
- Youth will complete pre, mid-year and post assessments as required by the grant funded contract.
- Parents/Guardians will participate in a survey process at least once per year.
- Youth third grade and older will participate in a satisfaction survey process at least once per year.
I have read, understand and agree to comply with the requirements of the policies and procedures listed above. I realize that failure to comply with these requirements may result in loss of my funded space within this program. I release the Teton Literacy Center, its staff, Board of Directors and volunteers from any liability.
Signature*

Clear

TLC Student & Family Expectations

Teton Literacy Center's Afterschool Enrichment Clubs and Tutoring Programs are free programs for students that promote school success and student wellbeing in a safe environment. In all of our Programs, we aim to guide student behavior in a positive way through providing examples and modeling desired behaviors as well as offering clear directions, reasoning and consequences. To accomplish the goals of our Programs, we have set out TLC’s expectations for our students and their families. Please take some time to review these expectations with your student before he or she starts our Programs.
Students must be respectful to the staff, volunteers and other students. Students must respect other's physical space, physical safety and feelings. Staff and volunteers must also be respectful of students.

Students and families understand that TLC Programs may include students from different schools and diverse cultures, religions, races, languages and ages. Students must be kind to all and accepting of each other.

The use of culturally, racially or religiously insensitive remarks, mimicry, foul language or profanity is not acceptable at any time and will not be tolerated.

All students and families are expected to know and follow the rules of both Teton Literacy Center and Teton County School District. All Teton County School District rules apply when students and families are in Teton Literacy Center Programs. These rules include playground protocol, wearing shoes at all times, sitting while eating snacks, using “inside voices” and walking in the hallways. These policies are put in place to keep all students safe.

Parents or guardians are responsible for picking up their child on time at the end of the program. Parents or guardians are also entirely responsible for arranging the student’s transportation to and from Programs.

Students must remain at their assigned locations for program activities until a parent or guardian signs them out or gives written permission for them to leave. If there is a change in pick-up plans – such as a student needs to leave early, will be picked up by someone else, or needs to walk home – their parent or guardian must notify instructors prior to 2:00 pm.

Students and families understand that there will be consequences for disruptive or dangerous behaviors, or for repeated violations of the rules set out here. The consequences, which are entirely at TLC’s discretion, will depend on the severity and persistence of the student’s behavior.

If there is a discipline problem, the TLC teacher will fill out a “Refocus Form” or “Incident Report,” depending on the severity of the problem. Parents or guardians will be notified in writing of the problem. TLC may schedule a family meeting. If the student persists in misbehaving after the family meeting, TLC may enforce a break in services while the student and family work to build more appropriate behaviors.

Acknowledgement of My Responsibilities as Parent or Guardian

I have read and understood the policies and procedures listed above and agree to comply with them. I have also reviewed these policies and procedures with my child. I understand that if my child or I fail to comply with these policies and procedures my child may lose his or her funded space within this program.
Signature*

Clear

Acknowledgement and Assumption of Risk, Release of Liability, and Indemnity and Hold Harmless for Out-of-School Programs
Acknowledgement and Assumption of Risk: I understand that my minor child’s participation in Teton Literacy Center’s (TLC) and Jackson Hole Children’s Museum’s (JHCM) out-of-school programs is voluntary and that my child and I are free to choose not to participate. I understand that participation in voluntary out-of-school activities includes risks, including risk of injury or illness that may range in severity from minor to disabling to catastrophic including even death. Although serious injuries are not common in supervised out-of-school programs, I understand that it is impossible to eliminate all risk. I acknowledge the existence of this range of risks, and knowingly and voluntarily assume them for myself and on behalf of my child.

Acknowledgement that My Child’s Participation is at TLC’s Discretion: I understand that my child is allowed to participate in TLC’s programs entirely at TLC’s discretion. My child has no right to participate. TLC may stop offering a program, change a program, remove my child from a program, change its rules and procedures applicable to a program, enforce its rules and procedures applicable to a program, impose conditions on my child’s participation in a program, and the like, entirely at its discretion.

Release and Waiver of Liability: I understand that TLC and JHCM, as well as their employees, officers, directors, agents, and volunteers (including without limitation any individual, business, or entity TLC and JHCM uses in providing such programs), will not be liable for personal injuries, accidents, illness, my reliance on TLC’s programs, emotional distress, or property damage of any kind or degree, in connection with my child’s participation in such activities, including without limitation those arising from negligence.

Indemnity and Hold Harmless Agreement: On behalf of myself and my child, I agree to release, hold harmless and indemnify TLC and JHCM, their employees, officers, directors, agents, and volunteers (including without limitation any individual, business, or entity TLC and JHCM uses in providing such programs), from any loss, cost, damage, or expense of any kind or degree, including without limitation all attorneys’ fees, costs, and dispute resolution expenses, which I or my child may have, directly or indirectly, in connection with my child’s participation in such activities.

Knowing and Voluntary Agreement:  I have read this Acknowledgement and Assumption of Risk, Release of Liability, and Indemnity and Hold Harmless for Out-of-School Programs (Acknowledgement and Release), and understand its terms, and understand that my child and I are giving up substantial rights, including without limitation the right to sue. I also understand my right to review this Acknowledgement and Release with advisers of my choice and I have had the opportunity to do so. I am signing this Acknowledgement and Release freely and voluntarily and intend by my signature to be a complete and unconditional release of liability to the greatest extent allowed by law.

Severability: If one or more part this Acknowledgement and Release is found to be unenforceable or illegal, the unenforceable or illegal part shall be severed from other parts of the Acknowledgement and Release without rendering the remaining parts unenforceable.
Signature*

Clear

Health History and Permission for Emergency Services

This Form must be filled out by each minor student’s parent or guardian before he or she is allowed to participate in TLC’s after-school programs.
Health Insurance Information
Does the student have medical/hospital insurance?

YesNo
If YES, please provide the carrier and group #
Health Information
Name of the student's physician
Phone # of the student's physician
Does the student have any physical or mental impairments or conditions that could affect participation in TLC’s activities and programs?

YesNo
If YES, please describe those impairments or conditions:
Allergies
List all known allergies to medications or drugs:
List all known food allergies, such as nuts, gluten:
List all known allergies to insects and animals, such as insect stings, animal dander:
List any other known allergies, such as environmental allergies like hay fever:
Medications Taken by the Student
Does the student use an epi pen?

YesNo
Other than or in addition to an epi pen, does the student take medication, including over-the-counter medications or non-prescription drugs, on a routine, daily, or frequent basis?

YesNo
If YES, please describe below:

This student takes medications on a routine, daily, or frequent basis as follows:
Med #1, dosage, and specific times taken each day:
Reason for taking medication:
Med #2, dosage, and specific times taken each day:
Reason for taking medication:
The student must bring enough medication to last the entirety of their time at TLC programming. The medication must be kept in the original packaging or bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. The student must coordinate his or her use of medication with TLC staff.
Restriction on Student’s Activities
Describe any physical or emotional limitation or restriction on the student’s activities:
Authorization of Medical Services

I have completed and reviewed this form and attest that the information it contains, including the student’s health history, is correct and complete as far as I know.

I understand that TLC will attempt to reach the responsible parent or guardian at the cell phone number provided above in the event of a serious accident, injury, episode, or other medical emergency involving the student.

I also understand that TLC and its staff may need to obtain or provide first aid or emergency medical or dental services for the student, and may need to do so before TLC is able to reach the responsible parent or guardian identified above.

I hereby grant TLC and its staff full authority to take whatever action it considers appropriate under the circumstances regarding the health and safety of the student, including obtaining emergency medical or dental services for the student. I understand that I am financially responsible to providers of any such medical or dental services to the student, including providers of transportation to those facilities, and that I am also responsible for dealing with my insurance carrier (if any).

I further consent to the transportation of the student to a medical facility, including without limitation in a private vehicle or ambulance.
Signature

Clear

Authorization and Release: Photos, Recordings, Interviews, Art, Writings
I understand that Teton Literacy Center may, from time to time during its interactions with students and their families, take photographs, conduct interviews, make videos and other recordings, and display or use participants’ artwork and writings, for a variety of institutional, educational, and informational purposes, including marketing and fundraising. On behalf of myself and my minor children, I broadly, voluntarily, and unreservedly (1) authorize Teton Literacy Center and its officers, agents, employees, successors, licensees, volunteers, and assigns (collectively, TLC), to do so, and (2) release TLC from all forms of actions or claims, and all types of redress, compensation, or relief, in any forum or venue, whether in the past, present, or future, arising from or associated with the subject matter of this Authorization and Release.

Consistent with this broad authorization and release, I authorize TLC to take photos and make videos and other recordings of me and my minor children and to and use those images, likenesses, and appearances (collectively, photos) without compensation of any kind to me or my minor children, for any institutional, educational, and informational purpose, including marketing and fundraising. I further authorize TLC to use my name, biography, personal information, data, and event, as well as those of my minor children, in connection with any such uses of the photos on the same terms. I understand and agree to the broad authorization and release outlined here and waive any right or interest that I or my minor children may have, including any right to inspect or approve the photos. My authorization and release, for myself and my minor children, is irrevocable and valid for TLC’s use of the photos in any place, manner, or media. The photos may be used in whole or in part, alone or with other photographs or recordings, and may be blurred or modified. I understand that all right, title, and interest in the photos belongs solely to TLC.
Do you give Teton Literacy Center the photographic rights described above?*

YesNo
If you answered yes to the question above, please sign here.

Clear

Student Information: Reading Habits & Attitudes
What is the student's attitude towards reading at home and school?
What kind of books does your student like to read?
What is your student's attitude towards writing?
What does your student like to write?
What are your student's interests and hobbies?
How long is your student able to focus on a singular task?

5 minutes10 minutes15 minutes20 minutes25 minutes30 minutesOther
What helps your student focus on a singular task?
What areas of literacy are you most concerned about for your child?
What would you like to see your child accomplish at TLC? *

I understand that there are many dynamics involved in matching students with a tutor, including TLC's dependency on volunteer availability, thus TLC cannot guarantee a space for my student. *

Clear

Multiple Student Registration
Do you want to apply for another student?

YesNo

Click submit in order to complete the application.

Participant Information
Participant Name

First NameLast Name
Gender

M-MaleF-FemaleO-Other
Race
Ethnicity
Birth Date (MM-DD-YYYY)

MonthDayYear
Date
Grade 2024-2025
School Attending 2024-2025
TCSD Teacher Name

First NameLast Name

Shared Information Consent
This authorizes Teton Literacy Center and Teton County School District #1 to share written or verbal information regarding my child’s academic performance, diagnosis, history, including medication, progress, psychological and educational testing, medical and legal information, social welfare and rehabilitation, reports and other materials that are relevant to my child's care. I give my permission for the staff of Teton Literacy Center, this 21st CCLC program with services located at Teton Literacy Center, Munger Elementary School, and Jackson Hole Middle School to review my child’s academic and behavior progress reports or their report card in order to document growth and progress in my child during his/her time in this before/after school or summer program. This includes attendance, academic performance, teacher surveys and information about whether my child has an identified exceptionality, an Individual Education Plan or Academic Improvement Plan, and suggestions from my child’s teacher(s) on how my child can best be helped in the program. TLC will send Wyoming Department of Education grade reports from your child’s teacher using WISERID numbers where data will be aggregated at the state level to protect your child’s identification. This data is collected to evaluate the effectiveness of TLC programs.

I understand that my records are protected under the laws regarding confidentiality, and cannot be disclosed without written consent, except in specific situations. This consent is valid throughout my child receiving services at Teton Literacy Center.
Signature

Clear

Acknowledgement and Assumption of Risk, Release of Liability, and Indemnity and Hold Harmless for Out-of-School Programs
Acknowledgement and Assumption of Risk: I understand that my minor child’s participation in Teton Literacy Center’s (TLC) and Jackson Hole Children’s Museum’s (JHCM) out-of-school programs is voluntary and that my child and I are free to choose not to participate. I understand that participation in voluntary out-of-school activities includes risks, including risk of injury or illness that may range in severity from minor to disabling to catastrophic including even death. Although serious injuries are not common in supervised out-of-school programs, I understand that it is impossible to eliminate all risk. I acknowledge the existence of this range of risks, and knowingly and voluntarily assume them for myself and on behalf of my child.

Acknowledgement that My Child’s Participation is at TLC’s Discretion: I understand that my child is allowed to participate in TLC’s programs entirely at TLC’s discretion. My child has no right to participate. TLC may stop offering a program, change a program, remove my child from a program, change its rules and procedures applicable to a program, enforce its rules and procedures applicable to a program, impose conditions on my child’s participation in a program, and the like, entirely at its discretion.

Release and Waiver of Liability: I understand that TLC and JHCM, as well as their employees, officers, directors, agents, and volunteers (including without limitation any individual, business, or entity TLC and JHCM uses in providing such programs), will not be liable for personal injuries, accidents, illness, my reliance on TLC’s programs, emotional distress, or property damage of any kind or degree, in connection with my child’s participation in such activities, including without limitation those arising from negligence.

Indemnity and Hold Harmless Agreement: On behalf of myself and my child, I agree to release, hold harmless and indemnify TLC and JHCM, their employees, officers, directors, agents, and volunteers (including without limitation any individual, business, or entity TLC and JHCM uses in providing such programs), from any loss, cost, damage, or expense of any kind or degree, including without limitation all attorneys’ fees, costs, and dispute resolution expenses, which I or my child may have, directly or indirectly, in connection with my child’s participation in such activities.

Knowing and Voluntary Agreement: I have read this Acknowledgement and Assumption of Risk, Release of Liability, and Indemnity and Hold Harmless for Out-of-School Programs (Acknowledgement and Release), and understand its terms, and understand that my child and I are giving up substantial rights, including without limitation the right to sue. I also understand my right to review this Acknowledgement and Release with advisers of my choice and I have had the opportunity to do so. I am signing this Acknowledgement and Release freely and voluntarily and intend by my signature to be a complete and unconditional release of liability to the greatest extent allowed by law.

Severability: If one or more part this Acknowledgement and Release is found to be unenforceable or illegal, the unenforceable or illegal part shall be severed from other parts of the Acknowledgement and Release without rendering the remaining parts unenforceable.
Signature*

Clear

Health History and Permission for Emergency Services

This Form must be filled out by each minor student’s parent or guardian before he or she is allowed to participate in TLC’s after-school programs.
Health Insurance Information
Does the student have medical/hospital insurance?

YesNo
If YES, please provide the carrier and group #
Health Information
Name of the student's physician
Phone # of the student's physician
Does the student have any physical or mental impairments or conditions that could affect participation in TLC’s activities and programs?

YesNo
If YES, please describe those impairments or conditions:
Allergies
List all known allergies to medications or drugs:
List all known food allergies, such as nuts, gluten:
List all known allergies to insects and animals, such as insect stings, animal dander:
List any other known allergies, such as environmental allergies like hay fever:
Medications Taken by the Student
Does the student use an epi pen?

YesNo
Other than or in addition to an epi pen, does the student take medication, including over-the-counter medications or non-prescription drugs, on a routine, daily, or frequent basis?

YesNo
If YES, please describe below:

This student takes medications on a routine, daily, or frequent basis as follows:
Med #1, dosage, and specific times taken each day:
Reason for taking medication:
Med #2, dosage, and specific times taken each day:
Reason for taking medication:
The student must bring enough medication to last the entirety of their time at TLC programming. The medication must be kept in the original packaging or bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. The student must coordinate his or her use of medication with TLC staff.
Restriction on Student’s Activities
Describe any physical or emotional limitation or restriction on the student’s activities:
Authorization of Medical Services

I have completed and reviewed this form and attest that the information it contains, including the student’s health history, is correct and complete as far as I know.

I understand that TLC will attempt to reach the responsible parent or guardian at the cell phone number provided above in the event of a serious accident, injury, episode, or other medical emergency involving the student.

I also understand that TLC and its staff may need to obtain or provide first aid or emergency medical or dental services for the student, and may need to do so before TLC is able to reach the responsible parent or guardian identified above.

I hereby grant TLC and its staff full authority to take whatever action it considers appropriate under the circumstances regarding the health and safety of the student, including obtaining emergency medical or dental services for the student. I understand that I am financially responsible to providers of any such medical or dental services to the student, including providers of transportation to those facilities, and that I am also responsible for dealing with my insurance carrier (if any).

I further consent to the transportation of the student to a medical facility, including without limitation in a private vehicle or ambulance.
Signature*

Clear

Authorization and Release: Photos, Recordings, Interviews, Art, Writings
I understand that Teton Literacy Center may, from time to time during its interactions with students and their families, take photographs, conduct interviews, make videos and other recordings, and display or use participants’ artwork and writings, for a variety of institutional, educational, and informational purposes, including marketing and fundraising. On behalf of myself and my minor children, I broadly, voluntarily, and unreservedly (1) authorize Teton Literacy Center and its officers, agents, employees, successors, licensees, volunteers, and assigns (collectively, TLC), to do so, and (2) release TLC from all forms of actions or claims, and all types of redress, compensation, or relief, in any forum or venue, whether in the past, present, or future, arising from or associated with the subject matter of this Authorization and Release.

Consistent with this broad authorization and release, I authorize TLC to take photos and make videos and other recordings of me and my minor children and to and use those images, likenesses, and appearances (collectively, photos) without compensation of any kind to me or my minor children, for any institutional, educational, and informational purpose, including marketing and fundraising. I further authorize TLC to use my name, biography, personal information, data, and event, as well as those of my minor children, in connection with any such uses of the photos on the same terms. I understand and agree to the broad authorization and release outlined here and waive any right or interest that I or my minor children may have, including any right to inspect or approve the photos. My authorization and release, for myself and my minor children, is irrevocable and valid for TLC’s use of the photos in any place, manner, or media. The photos may be used in whole or in part, alone or with other photographs or recordings, and may be blurred or modified. I understand that all right, title, and interest in the photos belongs solely to TLC.
Do you give Teton Literacy Center the photographic rights described above?

YesNo
If you answered "yes" to the question above, please sign here.

Clear

Student Information: Reading Habits & Attitudes
What is the student's attitude towards reading at home and school?
What kind of books does your student like to read?
What is your student's attitude towards writing?
What does your student like to write?
What are your student's interests and hobbies?
How long is your student able to focus on a singular task?

5 minutes10 minutes15 minutes20 minutes25 minutes30 minutesOther
What helps your student focus on a singular task?
What areas of literacy are you most concerned about for your child?
What would you like to see your child accomplish at TLC? *

Click submit in order to complete the application.
Should be Empty:

Monday	Tuesday	Wednesday	Thursday
Upper Elementary & Secondary	Upper Elementary & Secondary	Lower Elementary	Lower Elementary

	Monday	Tuesday	Wednesday	Thursday
3:00-4:00pm
4:00-5:00pm
5:00-6:00pm
5:30-6:30pm
6:00-7:00pm

Monday	Tuesday	Wednesday	Thursday
Upper Elementary & Secondary	Upper Elementary & Secondary	Lower Elementary	Lower Elementary

	Monday	Tuesday	Wednesday	Thursday
3:00-4:00pm
4:00-5:00pm
5:00-6:00pm
6:00-7:00pm

TLC Tutoring Program Application

Participant Information

Participant Education Information

Shared Information Consent

Family Information

Family Information

Family History

Emergency Contact

How will your child get to and from TLC programs?

Pick Up Consent

Policies and Procedures

TLC Student & Family Expectations

Acknowledgement and Assumption of Risk, Release of Liability, and Indemnity and Hold Harmless for Out-of-School Programs

Health History and Permission for Emergency Services

Health Insurance Information

Health Information

Allergies

Medications Taken by the Student

Restriction on Student’s Activities

Authorization and Release: Photos, Recordings, Interviews, Art, Writings

Preferred Tutoring Days & Times

Student Information: Reading Habits & Attitudes

Multiple Student Registration

Click submit in order to complete the application.

Participant Information

Participant Education Information

Shared Information Consent

Acknowledgement and Assumption of Risk, Release of Liability, and Indemnity and Hold Harmless for Out-of-School Programs

Health History and Permission for Emergency Services

Health Insurance Information

Health Information

Allergies

Medications Taken by the Student

Restriction on Student’s Activities

Authorization and Release: Photos, Recordings, Interviews, Art, Writings

Preferred Tutoring Days & Times

Student Information: Reading Habits & Attitudes

Click submit in order to complete the application.