K-12 Student Enrollment Form : Forms : What We Do : The Estes Park Learning Place

Date

Student Name:

First Name *

Last Name *

Student Date of Birth:

Month

Day

Year

Current Grade Level:

Current School

Student Gender

Student Ethnicity

If multiple ethnicity/ Other, please specify

(IF “Hispanic or Latino/a” NOT selected in previous question) Are you of Hispanic or Latino/a origin?

Main/Physical Address:

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Mailing Address (If different than main/physical address):

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Student Cell Phone if they have one

Student Email if they have one

Parent/Guardian #1:

First Name *

Last Name *

Phone:

Work Phone:

Email:

Parent/Guardian #2:

First Name *

Last Name *

Phone:

Work Phone:

Email:

Phone to Call First in Case of an Emergency:

Information about what services you need:

What subject does your student need help with?

Does your student REQUIRE a spanish speaking tutor?

Only pick Yes if student does not speak any English

Disability

Is there an IEP or 501 Plan in place?

Please share what you believe might be helpful to the tutor in working with you/your student as a learner. Information provided will be confidential.

Describe what the student needs help with in more detail

List your student’s strength(s)

List special interests and hobbies.

Please write anything else you would like to share that would be helpful.

Availabilities: We do our best to meet your Tutoring needs during the week. Please provide us with information on your students availability for tutoring.

Day (s) of the week

check all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday

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Times

(We tutor Monday through Friday 9-5:30 with afterschool tutoring occurring usually at 3:30 and 4:30. Daytime tutoring occurs on the hour 9-3pm) Please indicate all times available.

9:00 AM
10:00 AM
11:00 AM
Noon
1:00 PM
2:00 PM
3:30 PM
4:30 PM

How many sessions of tutoring desired per week:

Release of Student Records Informed Consent Form

I hereby request and give permission to the Estes Park Learning Place, Sue Yowell, Executive Director and authorized tutors to review, discuss, and receive copies of all student records for my student including cumulative records, grades, testing, anecdotal records of teacher comments, as well as, health information and all special education records. Further, I release the following school district from responsibility with regard to the release of this information and desire that school district personnel work cooperatively with the Estes Park Learning Place regarding my son’s/daughter’s educational program.

Photograph and Video Release

I hereby grant the Estes Park Learning Place and its affiliates permission to use photographs, video and/or audio. These photographs, video and/or audio may be used without identification by name in future publicity and communications of the Estes Park Learning Place for an indefinite period of time.

By submitting this enrollment application, you agree to abide by the Tutoring Agreement.

By submitting this application you agree that The Estes Park Learning Place reserves the right to terminate tutoring if we believe it is not the right fit.

K-12 Student Enrollment Form

Information about what services you need:

Please share what you believe might be helpful to the tutor in working with you/your student as a learner. Information provided will be confidential.

Availabilities: We do our best to meet your Tutoring needs during the week. Please provide us with information on your students availability for tutoring.

Release of Student Records Informed Consent Form

Photograph and Video Release

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