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Student Application

Please read this form carefully and complete the form in its entirety.

Step 1 of 8

12%

Date of Application*
Tutoring Day (check all that apply)*
- Tuesday
- Wednesday
Student Name*
FirstLast
Gender*
- Female
- Male
Address*
Street AddressAddress Line 2CityStateZIP Code
Student Cell Phone
Student Email
Birth Date*
Attended Cabrini Green Tutoring Program*
- Yes
- No
Ethnicity
Age*

Please enter a value between 1 and 100.

Grade in School (K-12)*
School Name*
Favorite Subject in School*
Subject You Would Like Help With*
Please check one*
- New student
- Returning student
How did you hear about us?*
What extracurricular activities are you involved in?*
- Art / drawing / painting
- Sports
- Music / play instrument
- Dance / cheerleading
- Writing / reading
- Games / videos
- Other
List other activities here.

Parent / Guardian Name*
FirstLast
Parent / Guardian Email Address
Parent / Guardian Home Phone
Parent / Guardian Cell Phone
Employer
Employer Phone Number

Emergency Contact Name*
FirstLast
Relationship to Student*
Emergency Contact Phone*

Please list names of all people (including student) in household, age, and relationship to student.*

Name	Age	Relationship

Please list any health problems or allergies.*

Add a row

Remove this row

Please list any disabilities or special needs.*

Add a row

Remove this row

Transportation consent.*
- I do not want my child to be transported by a volunteer to/from tutoring sessions.
- I do want my child to be transported by a volunteer to/from tutoring sessions and accept full responsibility as outlined in the Parent and Student Contract and Consent forms (please download, complete, and mail to Cabrini Connections, 800 W. Huron Street Chicago, IL 60642 ).
Besides the person signing this form, who else is allowed to pick up student?*
FirstLast
Relationship of this person to student.*

Please use the boxes below to ensure you are sending the appropriate further documentation needed to ensure your placement.*
- The student and the person completing this application have completed and signed the Parent and Student Contract.
- The student has completed and signed the Contract for Success for Students.
- The student and the person completing this application have completed and signed the Authorization for Release of Confidential Information and Consent Form.
- The student and the person completing this application have completed and signed the Client Intake Form.
Please send all required documents to:
CABRINI CONNECTIONS
800 W. Huron Street
Chicago, IL 60642

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