After School Tutorial Program

	Please select your school from the drop-down list.*
	-- Please Select --Apple Creek ElementaryBriarwood ElementaryBroadmoore ElementaryBryant ElementaryCentral ElementaryEarlywine ElementaryEastlake ElementaryFairview ElementaryFisher ElementaryHeritage Trails ElementaryHouchin ElementaryKelley ElementaryKingsgate ElementaryNorthmoor ElementaryOakridge ElementaryPlaza Towers ElementaryRed Oak ElementarySanta Fe ElementarySG-Rippetoe ElementarySky Ranch ElementarySooner ElementarySouthlake ElementaryTimber Creek ElementaryWayland Bonds ElementaryWinding Creek ElementaryBrink Junior HighCentral Junior HighHighland East Junior HighHighland West Junior HighMoore West Junior HighSouthridge Junior HIghMoore High SchoolSouthmoore High SchoolWestmoore High SchoolVISTA Academy

	Date:*
	mm/dd/yyyy

	Student's Name*

	Student's grade:*
	4th   5th   6th   7th   8th Eligible grades

	Parent Name with Home/ Cell and/ or Work Phone *

	E-mail address

	Gender:*
	-- Please Select --MaleFemale

	Please list current grades.*
	A   B   C   D   F English           Math           Science           Social Studies           Reading

	Students will be tutored for 50 minute sessions. Students may qualify for one or two sessions depending on current grades. This will be determined by site supervisor.

	Please list your 1st, 2nd and 3rd choice of locations. Days of service are listed next to each location.*
	1   2   3 Brink JH (Mon/Wed)       Highland East JH (Tues/TH)       Highland West JH (T/TH)       Moore West JH (Tues/TH)       Central JH (M/W)

	Please indicate the day you prefer to bring your student.*
	Monday   Tuesday   Wednesday   Thursday Tutoring is available Monday-Thursday. If you student qualifies for 2 sessions, these will be on Monday/Wednesday or Tuesday/Thursday.

	Please select your 1st, 2nd and 3rd choice of session times.*
	1   2   3 4:30-5:20       5:30-6:20       6:30-7:20

	Please allow one week before a site supervisor calls to schedule a time and day of tutoring. It is the reponsibility of the parent to provide transportation. The student responsibility is to bring books and supplies to each tutoring session.

	Is this student enrolled in any other special programs?
	-- None --Yes No

	Name of Home School Counselor

	I give my permission for my child to attend tutoring*
	-- Please Select --Yes No