STUDENT APPLICATION
Are you applying for the Virtual Summer Learning Program?
YES
NO
YES to Virtual and In-Person
Thank you for your interest in the South Rome Free Tutoring Program. Our goal is to provide academic support, mentoring, and encouragement to help students reach their full potential. Please complete this application in full. Submission does not guarantee placement. We will contact you within
7-10 business days.
1. STUDENT INFORMATION
Student Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Grade Level:
School Name:
Teacher's Name (if known):
2. PARENT/GUARDIAN INFORMATION
Parent/Guardian Name:
Relationship to Student:
Date of Birth - Guardian - Parent
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age (Parent - Guardian)
Email Address:
example@example.com
Primary Phone:
Format: (000) 000-0000.
Secondary Phone:
Format: (000) 000-0000.
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. EMERGENCY CONTACT INFORMATION
Emergency Contact Name:
Relationship to Student:
Phone Number:
Format: (000) 000-0000.
4. ACADEMIC NEEDS & SUBJECTS
What subjects does the student need help with? (Check all that apply)
Reading
Math
Writing
Science
Social Studies
Homework Help
Study Skills
Test Preparation
Organization
Confidence Building
Other:
Please describe the student's academic needs:
5. PROGRAM GOALS
What are your goals for this student? (Check all that apply)
Improve grades
Strengthen reading skills
Strengthen math skills
Complete homework consistently
Build confidence
Receive positive mentoring
Improve focus & study habits
Prepare for the next grade level
College & career readiness
Other:
What would success look like for your child?
6. ADDITIONAL INFORMATION
Has your child received tutoring before?
Yes
No
If yes, what subjects and for how long?
Are there any learning challenges or accommodation needs we should be aware of?
Yes
No
If yes, please explain:
How did you hear about us?
School
Friend/Family
Social Media
Community Event
Flyer/Poster
Website
Other:
7. AGREEMENT & PERMISSION
I give permission for my child to participate in the South Rome Free Tutoring Program.
I understand that attendance and participation are important for continued support.
I understand that program staff may contact me regarding my child's progress.
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
We're Here to Help! Our mission is to support every student academically and personally so they can build a brighter future. We look forward to partnering with your family!♡
PLEASE RETURN COMPLETED APPLICATION TO:
607 Pennington Ave.
Rome, GA 30161
706-591-3363
admin@southromefreetutoring.org
www.southromefreetutoring.org
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