Student Application | ::Back on Track::

"Education is all a matter of building bridges"
-Ralph Ellison

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Student Application

General Information

Student Last Name: *

Student First Name: *

Street Address: *

City: *

State: *

Zip Code: *

Public Housing: *

Yes

Homeless: *

Yes

Birthday: *

Age: *

School: *

Grade: *

Gender: *

Male

Female

Teacher/Guidance Counselors: *

Race/Ethnicity:

(for statistical purposes only)

Parent/Caretaker Information

Last Name: *

First Name: *

Relationship to Student: *

Home Phone:

Work Phone:

Cell Phone:

E-Mail Address:

Immigrant: *

Yes

Last Name:

First Name:

Relationship to Student:

Home Phone:

Work Phone:

Cell Phone:

E-Mail Address:

Languages

Primary language spoken at home:

Other languages spoken by the student:

Special Education

Is your student in special education classes?:

Yes

If yes, which ones?:

Does she/he have any special needs?:

Yes

If yes, which ones?:

How did you hear about Back on Track?

Select from the drop down:

Or radial buttons below:

School

Church

Friend/Relative

Newspaper

Please specify above choice:

Please specify which school, church, friend, relative or newspaper above you heard about us from.

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:

Dropping Off/Picking Up

Who will be dropping off the student?:

Who will be picking up the student?:

Does the student have permission to go home alone?:

Yes

Does the student have permission to go home early?:

Yes

Emergency Contact

(Other than Parent/Caretaker(s) listed above)

Last Name: *

First Name: *

Relationship to Student: *

Home Phone:

Work Phone:

Cell Phone:

Student's 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 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.

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 have submitted my child's SAT 9 score: *

Yes

I authorize Back on Track to contact my child's school/teacher/guidance counselor: *

Yes

May we disclose the student's phone number to the tutor?:

Yes

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 checking "I DO agree" you are signing this form: *

I DO agree

I DO NOT agree