» Student Application

Student Application


2016


If you are a returning student please click Returning Student Application Packet 16-17 

Name: *
Address: *
Public Housing *
CalWorks: *
Homeless *
Household Income: *
Birthdate *
Age *
School *
Grade *
Gender *
Teacher/Guidance Counselor *
Race Ethnicity *
(for statistical purposes only)

Parent/Caretaker Information
P/C Name: *
Relationship to student *
Home Phone: *
-
Work Phone:
-
Cell Phone: *
-
E-mail: *
Immigrant *
Languages
Primary language spoken at home *
Other languages spoken by the student *

Special Education
Is your student in special education classes? *
If yes, which ones?
Does she/he have any special needs? *
If yes, please state needs
How did you hear about Back on Track? *
Or radial buttons:
Please select those the pertain
Please specifiy above choice

Enrollment Activities
My child is interested in
Please specify other

Tutoring and Site Times
Please rate tutoring session times, from 1 to 3 in order of preference with 1 being your first choice. Please note K-2nd grade 3:30pm sessions only.
Third Baptist Church 1399 McAllister @ Pierce

1st Choice *
2nd Choice
3rd Choice

Dropping Off/Picking Up
Who will be dropping the student off? *
Who will be picking the student up? *

Emergency Contact
Emergency Contact Name: *
Relationship to the student? *
Emergency Home Phone *
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Emergency Work Phone:
-
Emergency Cell Phone: *
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Students Medical Information

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 card MUST be submitted to process this application.
  • 2. 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.
Upload a File (Report Card): *
I authorize Back on Track to contact my child's school/teacher/guidance counselor *
May we disclose the student's phone number to the tutor? *
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?

Signature/Authorization
Your agreement (check below) 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.
Today's Date *
By selecting "I DO agree" you are signing this form *

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