STUDENT APPLICATION:

Student Name:

Last First

Street Address:

City, Zip Code

Birthday: Age: School: Grade:

Gender: Male Female Teacher/Guidance Counselors:

Race/Ethnicity (for statistical purposes only):

II. Parent/Caretaker Information

First Name Last Name Relationship to Student

Home Phone Work Phone Cell/Pager Email Address

First Name Last Name Relationship to Student

Home Phone Work Phone Cell/Pager

III. Languages

Primary Languages spoken at home:

Other Languages spoken by the student:

IV. Special Education

Is your student in special education classes? Yes No

If Yes, which ones:

Does she/he have any special needs? Yes No

If Yes, which ones:

V. How did you hear about Back on Track?

School:

Church:

Friend/Relative:

Newspaper:

VI. Enrichment Activities

My child is interested in:

Art Computers Sports Writing Theater

Music Science Outdoors Animals Other:

Tutoring Sites and Times: Please rate tutoring session times, from 1 to 3 in order of preference with 1 being your first choice. Please select AT LEAST one evening session.

Third Baptist Church 1399 McAllister @ Pierce

First Choice

Second Choice

Third Choice

VII. Dropping Off/Picking Up

Who will be dropping off the student?

Who is authorized to pick up the student?

Does the student have permission to go home alone? Yes No

Does the student have permission to go home early? Yes No

VIII. Emergency Contact (Other than Parent/Caretaker(s) listed above)

Name: Relationship to Student:

Phone Number: Home Work Cell/Pager

Student's Medical Information - Please list any medical conditions we should be aware of:

IX. Report Cards/SAT 9/School Contact

1. Report cards help Back on Track keep track of your child's progress in school and let us know where he/she needs the most work. Please forward a copy of all student report cards to Back on Track when you receive them. *A current report cardMUST be submitted to process this application.

2. The SAT 9 (Stanford Achievement Test) is mandated by the state of California. These test scores let us know at what grade level your child is performing and consequently help us create an individualized curriculum addressing his/her needs. *Current SAT 9 test results MUST be submitted to process this application. I have enclosed my child's SAT 9 scores: Yes No

3. In order to serve your child's academic needs to the best of our abilities, we may need to contact his/her teachers/guidance counselors to coordinate our efforts towards his/her success.

I authorize Back on Track to contact my child's school/teacher/guidance counselor: Yes No

Back On Track strives to protect the privacy of its participants. For convenience and scheduling purposes will you give permission to disclose your student's phone number to the tutor with whom they are matched?

Yes No If Yes, please specify which number to disclose (circle one): Home Work Other:

X. Signature/Authorization

Your signature assures that the above information is accurate and correct to the best of your knowledge. It also confirms authorization for your child to receive tutoring through Back on Track.

In case of an emergency, I authorize BOT to arrange the necessary transportation and medical care for my student/child. I hereby assume full responsibility for any risk of bodily injury or property damage that may occur.

Parent/Caretaker Signature: Date: