The Spirit of Excellence Tutorial Registration Form

Transcription

1 The Spirit f Excellence Tutrial Registratin Frm Applicatin Checklist Original registratin Original registratin frm (n fax/electrnic frm (n fax/electrnic cpies will be cpies accepted) will be accepted) Als be prepared Als be t prepared submit the t fllwing submit the with fllwing: yur applicatin: Supprting Supprting Dcuments Dcuments Teacher questinnaire ( included in applicatin) Guilfrd Cunty Schls Tw-Way cnsent frm EOG test scres (t be supplied by teacher n their questinnaire) EOG test scres Cpy f yur child(ren) s last reprt card COMPLETED teacher survey/questinnaire ( yu can use yur child s teacher Cpy f yur child s IEP (Individualized Educatin Plan), if applicable frm the previus schl year if accessible) Cpy f yur child(ren)last reprt card Schlarship Applicants Only Cpy f yur child s IEP (Individualized Educatin Plan), if applicable TANF r Wrkfirst eligibility letter r Free r Reduced lunch verificatin letter Name f student: Name f Parent: Date:

2 Dear Parent/Guardian, Attached is the applicatin frm fr ur Spirit f Excellence (SOE) Tutring Prgram. We are hnred that yu have chsen Black Child Develpment Institute f Greensbr, Inc. (BCDI-G) t help in creating a path twards academic success fr yur child. Please see infrmatin belw regarding the prcess fr entry int the prgram. Ø Eligibility: The SOE prgram is pen t all students in Guilfrd Cunty schls (K-12 th grade) regardless f race, religin, creed r sci-ecnmic backgrund. Ø Registratin: T register yur child fr the SOE prgram a parent r guardian must cmplete the tutr applicatin frm available nline r in ur ffice at 1200 East Market Street. Once the frm is cmpleted the riginal dcument (faxes are nt accepted) shuld be returned t ur ffice. Yu will receive a fllw up phne call t schedule an assessment fr students (K-5 th grade), upn receipt f all sectins f the frm. This prcess is very imprtant as it allws us t create an individualized plan t help yur child reach their academic gals. Ø Fees: There will be a ne-time, nn-refundable enrllment fee fr each child enrlled in the SOE prgram. Fr the enrllment fee is $30 per child. Please nte that fr thse families wh request a schlarship fr the prgram (reducing the payment t $15 fr the year), yu must supply need verificatin either by prviding a)tanf r WrkFirst verificatin dcuments r b) Free r Reduced Lunch verificatin dcument. Payment will be due nce a child is placed at a tutring site and prir t starting the tutring sessin. Ø Subjects: BCDI-G s gal is t help yur child imprve their academic skills in the areas f math r reading. Please nte that the primary fcus f the tutring sessin is t help yur child strengthen his/her skills as identified thrugh the assessment. Thugh tutrs will be available t assist with hmewrk they are nt respnsible fr ensuring that a student s hmewrk is cmpleted during the scheduled tutring time. Ø Days and Hurs fr Tutring: Tutring will ccur twice per week n alternative days (M/W r T/R) and hurs f tutring will vary by site lcatin and availability f tutrs. Please see schedule n the applicatin frm. BCDI-G recgnizes that there will be times when it is necessary fr a student t miss a tutring sessin. Hwever, regular attendance is required in rder t prvide the mst beneficial service. If the student is t be absent, please cntact the BCDI-G ffice befre 2:00 pm. Frequent absences will result in terminatin frm the site. If a student is absent twice withut ntificatin they will be drpped frm the prgram. Als nte that the tutring sites are clsed when Guilfrd Cunty Schls are clsed this includes teacher wrkdays and hlidays. At BCDI-G we believe that parents/guardians are a child s first teacher. We are lking frward t this cllabratin with yu, Guilfrd Cunty Schls, ur AmeriCrps Members, cmmunity vlunteers and BCDI-G staff where tgether we will be wrking t ensure yur child s academic success. Please sign yur name that yu have read and understd these guidelines: à 1200 East Market Street Greensbr, Nrth Carlina Phne: (336) Fax: (336) Inf@BlackChildDevelpment.rg Website: Page 2 f 7

3 The Spirit f Excellence Tutrial Registratin Frm Cmmunity Based Tutring Sites Please cmplete the frnt and back f each page and submit the riginal dcument (n electrnic r faxed frms will be accepted). Please have yur child s teacher cmplete the Teacher Questinnaire frm. All frms shuld be returned t ur main ffice. Once all cmpleted frms are returned, yu will receive a fllw-up call frm ur ffice t schedule the assessment fr this child. STUDENT INFORMATION: Student Name: Date f Birth: Age: Sex: Schl Attending: Grade: Des yur child receive Exceptinal Children s Service and/r have an IEP: N Yes (if yes, please specify) Please nte any learning challenges that the tutr wuld need t knw abut t best assist yur child. Additinal Infrmatin that wuld be helpful in wrking with yur child: PRIMARY SUBJECT IN WHICH TUTORING IS BEING REQUESTED: (please chse ONE subject nly) Reading/English -OR- Math (if 6th grade r higher, please indicate type) ARE YOU ELIGIBLE TO RECEIVE A SCHOLARSHIP? (reducing the fee t $15 fr the year) Yes** N **please nte, additinal dcumentatin is required t prve yur eligibility. These dcuments are: a) TANF r WrkFirst verificatin dcuments OR b) Free r Reduced Lunch verificatin dcument 1200 East Market Street Greensbr, Nrth Carlina Phne: (336) Fax: (336) Inf@BlackChildDevelpment.rg Website: Page 3 f 7

4 Please Select Tutring Site and Time Preference Belw Site Available Days Preferred Time Please Select ONLY ne Secndary Preference Please Select ONLY ne (T be determined) Mnday and Wednesday 3:00 pm t 4:00 pm 4:00 pm t 5:00 pm 5:00 pm t 6:00 pm 6:00 pm t 7:00 pm 3:00 pm t 4:00 pm 4:00 pm t 5:00 pm 5:00 pm t 6:00 pm 6:00 pm t 7:00 pm (T be determined) Tuesday and Thursday 3:00 pm t 4:00 pm 4:00 pm t 5:00 pm 5:00 pm t 6:00 pm 6:00 pm t 7:00 pm 3:00 pm t 4:00 pm 4:00 pm t 5:00 pm 5:00 pm t 6:00 pm 6:00 pm t 7:00 pm Please Nte: BCDI-G recgnizes that there will be times when it is necessary fr a student t miss a tutring sessin. Hwever, regular attendance is required in rder t prvide the mst beneficial service. If the student is t be absent, please cntact the BCDI-G ffice befre 2:00 pm. Frequent absences will result in terminatin frm the site. If a student is absent twice withut ntificatin they will be drpped frm the prgram. Als nte that the tutring sites are clsed when Guilfrd Cunty Schls are clsed this includes teacher wrkdays and hlidays East Market Street Greensbr, Nrth Carlina Phne: (336) Fax: (336) Inf@BlackChildDevelpment.rg Website: Page 4 f 7

5 Parent/Guardian Infrmatin: Parent/Guardian Name: Address: City: State: Zip: Hme Telephne N.: Wrk N.: Cell Phne N.: The best way t cntact me is: cell phne hme phne Emergency Cntact (REQUIRED) Phne Number: Hw did yu hear abut BCDI-G s tutring prgram? schl friend PSA ther Parent/Guardian Agreement Please initial: I give Black Child Develpment Institute f Greensbr, Inc. (BCDI-G) permissin t btain academic infrmatin frm my child s Guilfrd Cunty Schl (GCS) Recrds. I give BCDI-G permissin t cmmunicate with GCS fficials (ie: teachers, cunselrs, scial wrkers, etc.) I give BCDI-G permissin t take phtgraphs fr prmtinal purpses. I understand that I must prvide BCDI-G with my child s reprt card after each grading perid. I understand that I must prvide BCDI-G with my child s EOG scres frm the previus academic year at the beginning f each prgram year. I understand that I will be respnsible fr transprtatin t and frm the prgram and that BCDI-G and/r their representatives may nt transprt my child at any time during the prgram. I understand that failure t prmptly pickup my child frm each sessin culd result in dismissal frm the prgram. I understand that if my child will be absent, I must cntact the BCDI-G ffice befre 2:00 pm. I understand that if my child is absent twice withut ntificatin they may be terminated frm the prgram. Parent Signature: Date: 1200 East Market Street Greensbr, Nrth Carlina Phne: (336) Fax: (336) Inf@BlackChildDevelpment.rg Website: Page 5 f 7

6 Please be advised that cmpletin f the infrmatin belw is OPTIONAL and des NOT affect yur applicatin fr services. Hwever, this frm ensures that we have accurate infrmatin abut the families we serve and can prvide required feedback t the funding agencies that supprt ur rganizatin. Husehld Makeup: Single Parent (Female) Single Parent (Male) Tw Parent Grandparent/Caregiver Other Age f Parents/Caregivers: Ethnicity (check all that apply): African African American/Black Asian r Pacific Islander Caucasian/White Hispanic/Latin Native American r Alaskan Native Other 1200 East Market Street Greensbr, Nrth Carlina Phne: (336) Fax: (336) Number f CHILDREN in Husehld: # f Females # f Males Inf@BlackChildDevelpment.rg Website: Annual Husehld Incme: under $10,000 $10,000 t $19,999 $20,000 t $29,999 $30,000 t $39,999 $40,000 t $49,999 ver $50,000 Unemplyed Name f Emplyer: Highest Level f Educatin Cmpleted: High Schl Diplma r GED Vcatinal/Tech Schl Bachelrs Degree Masters Degree Dctral Degree Other Are yu a Member f the PTA? Yes N Thank yu fr prviding us with this infrmatin! 1200 East Market Street Greensbr, Nrth Carlina Phne: (336) Fax: (336) Inf@BlackChildDevelpment.rg Website: Page 6 f 7

7 Teacher Questinnaire Name f Student: Name f English Teacher: Name f Math Teacher: Name f Schl: English Teacher Cntact Inf: Phne Math Teacher Cntact Inf: Phne Is this student wrking belw grade level in either area f study? Yes N Please circle the EOG scring f the student: Reading Level Math Level Written Language T be cmpleted by teacher: What kinds f activities (learning strategies) d yu feel wuld be mst helpful t this student? On a scale f 1 t 5, 1 being Pr and 5 being Excellent, please grade the student in the fllwing: Cmprehends ral instructins Recalls/applies previusly learned materials Cmpletes hmewrk in a timely manner Prepared and rganized Cmpletes class assignments Listens attentively and carefully Seeks help when needed Takes pride in wrk Demnstrates effrt Please indicate bjectives that wuld be beneficial fr the tutr t wrk n with this student: 1200 East Market Street Greensbr, Nrth Carlina Phne: (336) Fax: (336) Inf@BlackChildDevelpment.rg Website: Page 7 f 7