James Samaritan Homework Helpers STUDENT Re-Enrollment Application
Thank you for participating in our Homework Helpers program. Please take some time to provide us with good feedback from last semester, as well as give us direction/goals for our next semester together.
Parent Name
*
First Name
Last Name
Parent Phone Number
*
Please enter a valid phone number.
Parent Email
*
example@example.com
Student Name
*
First Name
Last Name
What School will your student be attending next semester?
*
Student Grade Level
*
What day/days is your student available to attend Homework Helpers?
*
Please Select
Tuesday
Thursday
Both
What time do you expect to be able to arrive at James Samaritan?
Arrive as early as 3:20. All students have to be on campus by 4pm in order to participate.
Feedback from Previous Semester
Let us know how we did!
1st - Complete this for your student
What growth/success have you seen with your student, as a result of participating in this program in the past?:
*
Completing assignments on time, and turning into teacher
Improved test scores
more confidence in a subject
Improvement with academic skills
More emotional regulation, and communication from student
Final Report card improvement
Other
If "other," please specify
What is one WIN you and your student experienced last semester, as a result of participating in Homework Helpers?
*
Constructive Feedback - What is one area of growth/change you would like to see in the Homework Helpers program?
We acknowledge that there is no perfect program out there, and would love to hear any areas where you and your family feel we could improve our services.
My Child feels confident with his/her academic tasks
*
Not at all
1
2
3
4
5
6
7
8
9
Fully Confident
10
1 is Not at all, 10 is Fully Confident
2nd - Complete this for yourself and your family
If enrolling multiple students, please only feel obligated to complete this part of the survey one time.
Do you feel supported by James Samaritan in your student's academic success?
Not supported at all
1
2
3
4
5
6
7
8
9
Fully supported
10
1 is Not supported at all, 10 is Fully supported
If so, please let us know one way that james Samaritan have been a support to you
If not, please let us know how we can better support you, and your family.
What other programs/services has your family participated in with James Samaritan?
Back to School "Cutz & Kicks" event
Royal Family Kids Camp
Life Network Mentoring (ages 16-21)
Thanksgiving Dinner Baskets
Christmas Angel Tree
Foster the Family Monthly Support Group
Sports/activity sponsorship
None of the Above
Other
Submit
Should be Empty: