Harambee Program-Tutoring Intake Form

Harambee Program-Tutoring Intake Form
Generously funded by the County of Simcoe. Parents Against Racism Simcoe County is excited to be able to offer this support to the community. PARSC's fully funded spaces are intended to help families access an initial round of tutoring at no cost. Students who have already completed a free tutoring cycle may be asked to contribute towards sessions based on the sliding scale. We will always consider financial barriers. If you need help with this form or have any questions, please email harambee@parsc.ca
*Indicates required question
1. Child's grade
2. Parent/Caregiver first and last name

First NameLast Name
3. Child first and last name

First NameLast Name
4. Child's date of birth

MonthDayYear
Date
5. Child's grade in school

13. If no, list emergency contact information here-Full name, address with postal code and phone number
14. Relationship of emergency contact
15. Please list any diagnosis or learning needs the tutor should be aware of.
16. Does your child have an IEP? (Individual Education Plan)

17. Please select the session you would like to register for
18. Do you have interest in Empowerment Academy? A program that focus on a path to success for Black students, fostering academic achievement, leadership development, and a strong sense of cultural identity.
19. Do you require support with transportation?
20. Do you need to borrow a Chromebook? (For virtual sessions)

21. Tell us about your child's likes, dislikes etc.
22. Please indicate your income range.
23. Are you interested in a monthly subscription, that allows access to 2 sessions a week?

24. Additional comments
25. The information you have provided above is truthful and you consent to PARSC contacting you.
Should be Empty: