Tutor Application | ::Back on Track::

General Informaton

Today's Date:

Last Name: *

First Name: *

Street Address: *

City: *

State: *

Zip Code: *

Email: *

Home Phone:

Work Phone:

Cell Phone:

Occupation:

Employer:

Date of Birth:

Gender:

Male

Female

Emergency Contact:

Emergency Contact Phone Number:

Relationship:

Race/Ethnicity:

(for statistical purposes only)

How did you hear about us?:

Employer

School

Friend/Relative

Volunteer Org./Referral Svs.

Please select one of the options and include the details in the space provided to better identify the source.

How did you hear about us details:

Please add the details from above. For example: if you choose "School" tell us which school.

Or was it from one of these sources?:

Or did you hear about us from one of these sources?

Tutoring Sites and Times

All tutors are expected to commit to one session per week through the end of the school year. Please enter your choice of tutoring session times in order of preference. Please consider a 3:30 pm. time slot.

First Choice:

Second Choice:

Third Choice:

Areas of Interest:

Special Events/Field Trips

Computer/Technical Support

Substitute Tutoring

Public Relations/Fundraising

Please check areas of interest for other volunteering opportunities with Back On Track

Experience

Do you have any prior volunteer experience?:

Yes

If yes, please describe:

(age, activities, responsibilities, etc.)

What talents/skills/interests do you bring to Back On Track?:

What interest you most about volunteering at Back On Track?:

References

Please list two references

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Phone Number Disclosure :

Yes

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

Which Number?:

Home

Work

Cell

If Yes, please specify which phone number to disclose (seleect one)

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