#1 Student Enrollment Form

We are excited to offer your child personalized one-to-one reading lessons with our trained coaches through PEAK Literacy, using Great Leaps—a research-based, highly effective reading intervention.
High impact tutoring involves frequent, personalized sessions with a tutor. The goal is to provide consistent support and practice to help your child understand and retain key concepts. For this reason, tutoring takes place Monday-Thursday for 15 minutes between 2:30pm-9:00 pm.at the same time each day.

Available tutoring times vary. After your child's intake appointment you will select from available time slots.
There are four forms you will need to fill out to complete your child's enrollment. The estimated time for completion is approximately 20 minutes.

Privacy and Data Protection: Your privacy is of utmost importance to us. Rest assured that your personal data and information will never be shared. The data we collect will be used in the aggregate for reporting and applying to granting agencies. Personally-identifying information is never utilized in these activities.
Student's Name*

First NameLast Name
Student's Gender*

MaleFemaleNon-binaryPrefer to self describe
Student's Race/Ethnicity*

AsianHawaiian/Pacific IslanderAmerican Indian or Alaska NativeWhite/CaucasianBlack/African AmericanLatino/HispanicMultiracialOther
Student's Date of Birth: This information helps us determine appropriate reading levels.*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The student is in ___grade for the 2025/26 school year*
The student is attending ________ (insert name of school) for the 2025/26 school year.*
Name of School
The student's current/most recent grade in Reading/ELA is:*

ABCDFSNU
Has the student been diagnosed with a learning disability related to reading

YesNoUnsure
Check all that apply:

This student has an IEPThis student has a 504 PlanThis student has been diagnosed with a reading-related learning disability (e.g., dyslexia)This student has been evaluated for reading difficultiesThis student has been retained (repeated a grade)None of the above
What is the primary language spoken in the home?*
Is English your child's first language?*

YesNo
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Email*
example@example.com
Parent/Guardian #1 Cell Phone Number*
.Format: +1 (000) 000-0000.
I agree to receive meeting reminders via SMS from PEAK Literacy as well as updates in regards to my child's lessons (no more than 2/week). Opt out by replying STOP to cancel
What is the highest level of education Parent #1 has completed?*
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Cell Phone Number
.Format: +1 (000) 000-0000.
I agree to receive meeting reminders via SMS from PEAK Literacy as well as updates in regards to my child's lessons (no more than 2/week). Opt out by replying STOP to cancel
What is the highest level of education Parent #2 has completed?
How many people are in your family/household?*
Household Yearly Income*
Does the student qualify for free/reduced lunch?*
How did you hear about us? Select all that apply.*

A friend or family memberA current or previous parent of a studentPEAK staff or board memberA school employeeEventWebsiteFacebookInstagramAd at Gainesville Health and FitnessOther
Who, if anyone, may we thank for referring you?
Has your child worked with a PEAK tutor before? If so, is there a tutor you’d like to request? (Please note: we cannot guarantee tutor availability.)
Enter Tutor name here
After submitting, you will be directed to form 2/4
The student will complete their tutoring lessons at:*

HomePineridge NeighborhoodResidences at OakviewUnknown/Other
Should be Empty:

We are excited to offer your child personalized one-to-one reading lessons with our trained coaches through PEAK Literacy, using Great Leaps—a research-based, highly effective reading intervention.

There are four forms you will need to fill out to complete your child's enrollment. The estimated time for completion is approximately 20 minutes.

After submitting, you will be directed to form 2/4