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The Success Center
THE SUCCESS CENTER
TUTORING AND MENTORING
MENTORING +
VOLUNTEER WITH US
Tutoring and Mentoring Registration
Student General Information
First Name
Last Name
Address 1
Address 2
Country
City
State
Zip/Postal Code
Birth Date
Gender Identity
Medical Concerns/Allergies/Medications
Parent / Guardian Information (Primary Contact Person)
First Name
Last Name
Email Address
Contact Number
Relationship to Student
Parent / Guardian Information
First Name
Last Name
Email Address
Contact Number
Relationship to Student
I authorize this individual to pick up my child?
Yes
No
Emergency Contact Information
First Name
Last Name
Contact Number
Relationship to Student
I authorize this individual to pick up my child?
Yes
No
Student Academic Information
School
Grade
Does this student have an IEP or 504 plan with their school?
Yes
No
If yes, please elaborate.
In what areas/subjects does your child excel?
In what areas/subjects does your child struggle?
Anything else you'd like to share?
Teacher Information
May we contact your child's teacher for assistance with tutoring areas? If yes, please provide the teachers information below.
Yes
No
Teachers First Name
Teachers Last Name
Teachers Email Address
Teachers Phone Number
Photography Waver
By selecting "I approve" below, I hereby give permission for First Lutheran Church, and its designees to utilize photographs taken of me for the purposes of publicity on web sites, newsletters, brochures, or other media. I understand that such photographs are the sole property of First Lutheran and its designees to use as needed for stated purposes. Further, I relinquish any right to compensation for their use.
I approve
I decline
Final Verification and Submission
I verify that all the provided information is correct, and acknowledge that by submitting this form I am signing my child up to attend The Success Center: Tutoring and Mentoring.
Check here to verify
Submit Registration
