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Class of 2016
Abena
Alyce
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Justin
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Taveisha
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
*
First
Last
Gender
*
Female
Male
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP 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
*
First
Last
Parent / Guardian Email Address
Parent / Guardian Home Phone
Parent / Guardian Cell Phone
Employer
Employer Phone Number
Emergency Contact Name
*
First
Last
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.
*
Please list any disabilities or special needs.
*
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?
*
First
Last
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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