TLC Tutoring Program Application

Before completing this application, please note that Teton Literacy Center ONLY offers English literacy tutoring.

Please fill out all the required field to place your student on the wait list for tutoring. Please note that completing this application DOES NOT guarantee your student a space in our program, as there are many dynamics involved in matching students with a tutor, including our dependency on volunteer availability. 

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.

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 3 unexcused absences.(Only unplanned emergencies and illnesses are excused absences) Parents or student must call to inform staff in advance if they will not be attending that day (307-733-9242). 
• Students' assigned day and time cannot be changed. Please commit only if you can attend, as schedule changes will not be accommodated.
• 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.  

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. 

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.   

Choice of Law and Venue: This Acknowledgement and Release shall be interpreted according to the laws of the State of Wyoming and the venue shall be in Wyoming.

If YES, please describe below:

This student takes medications on a routine, daily, or frequent basis as follows: 

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.

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.   

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.

Tutoring Scheduling Update: 

As a means to increase efficiency and lesson effectiveness, we are planning to prioritize days by designated student grade levels. Please take this into consideration when listing your students availability.

Please let us know what days and times of the week your student is available to attend tutoring. The more availability you list, the easier it will be for us to quickly match your student and get them enrolled in our tutoring program. 

All TLC tutoring sessions take place Monday-Thursday from 3pm-7pm. 

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.

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.   

If YES, please describe below:

This student takes medications on a routine, daily, or frequent basis as follows: 

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.

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.   

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.

Tutoring Scheduling Update: 

As a means to increase efficiency and lesson effectiveness, we are planning to prioritize days by designated student grade levels. Please take this into consideration when listing your students availability.

Please let us know what days and times of the week your student is available to attend tutoring. The more availability you list, the easier it will be for us to quickly match your student and get them enrolled in our tutoring program. 

All TLC tutoring sessions take place Monday-Thursday from 3pm-7pm. 

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.

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.  

If YES, please describe below:

This student takes medications on a routine, daily, or frequent basis as follows: 

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.

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.   

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.

Tutoring Scheduling Update: 

As a means to increase efficiency and lesson effectiveness, we are planning to prioritize days by designated student grade levels. Please take this into consideration when listing your students availability.

Please let us know what days and times of the week your student is available to attend tutoring. The more availability you list, the easier it will be for us to quickly match your student and get them enrolled in our tutoring program. 

All TLC tutoring sessions take place Monday-Thursday from 3pm-7pm.