Literacy Council of Sumner County
Student Application

Student Information
Name
Date
Address
Home Phone
City, State Zip
Cell Phone
Employer
Work Phone
Email
Emergency Contact Person
Emergency Contact Phone
How did you hear about us? ___TV	___Newspaper	___Friend
Other languages spoken

For Statistical Purposes Only (Voluntary information)
Sex  ___  Female  ___  Male	                                                               Birthday_______________
Marital Status__________________________	                               Race___________________


If student is a minor, complete parent or guardian information below.
Name
Date
Address
Home Phone
City, State, Zip
Cell Phone
Employer
Work Phone
Email

Education
Highest grade completed
School
Tell us about your experience:






Conditions that may affect tutoring (vision or h earing impairment, mental, physical or learning disability, ADD, ADHD, etc...



Previous tutoring received:
Subject(s)
When

Tutoring Needs:
Reading___Writing___Grammar___Math___ESL___Other___
How many hours per week are you available for tutoring?
What times?
What days?
Location/town?
What age tutor do you prefer?                                                                 Male or Female?
Any other preferences?

What are your interests and hobbies?



Notice to all applicants: The Literacy Council of Sumner County (LCSC) reserves the right to conduct background checks on all applicants. This document and all other applicable forms will be secured and filed according to LCSC Board of Directors published guidelines.

RELEASE OF INFORMATION

I, ___________________________give permission to the Literacy Council of Sumner County to release information about my/my child's test results and other information pertinent to my/my child enrolling in in the Literacy Program. This information will be shared only in confidence with the assigned tutor and/or teacher.

STUDENT CONTRACT (to be read to student)

I want to enter the student tutoring program. Therefore, I promise to do daily homework as assigned by my tutor. I do understand and admit that regular and daily attention to my studies will increase my skills. I will remember to be goal-oriented and to respect the energies of my tutor.

WAIVER AND RELEASE FOR STUDENTS

In consideration of my being allowed to be involved in the literacy program sponsored by the Literacy Council of Sumner County (LCSC), I hereby agree to release and forever discharge the LCSC and all its volunteers, employees, officials, directors and agents, for any and all claims, demands, actions and lawsuits for injuries and expenses sustained and/or incurred to my person and/or property as a result of my involvement with LCSC. I understand that as a participant my activities may involve physical activity, contact with unidentified and unfamiliar persons, travel, and other potential risks of injury to me and my property, and I hereby assume all such risks.

Signature______________________________

Print Name_____________________________

Parent or Guardian_____________________

Address________________________________

City, State, Zip_______________________

Date___________________________________

Witnessed by___________________________

LCSC Board of Directors does not approve of:
1.Meeting in a home or other non-public location.
2.Allowing tutor or student to provide transportation for tutoring session.
3.Conducting tutoring session of a minor without parental (or guardian) supervision.
4.Not keeping scheduled appointments.
5.Having others besides parents/guardians attend sessions.


LCSC Notes:

Date of interview___________	Date enrolled_____________        Date closed_________________