Tutoring Program Registration Form You must have JavaScript enabled to use this form. Student Information Full Name First Last Date of Birth Age Grade Level Current School Attending Teacher(s) Gender Female Male Non-Binary Prefer not to answer Race/Ethnicity (Optional) African American/Black Caucasian/White Hispanic/Latino Asian/Pacific Islander American Indian/Alaskan Native Multiracial Prefer not to answer Other Enter other… Academic Support Needs Reading & Writing Reading Writing Spelling None of the above Mathematics Basic Math Algebra I Algebra II Geometry Trigonometry None of the above Science & Social Studies Biology Chemistry Social Studies None of the above Other Other Support Needed Parent/Guardian Concerns or Goals for Tutoring Please describe the specific academic areas, skills, or goals you would like tutors to focus on Has the student previously received tutoring or academic support? No Yes If yes, please explain briefly Does the student have any learning accommodations? (optional) No Yes If yes, please explain Parent/Guardian Information Parent/Guardian Name Relationship to Student Email Address Cell Phone Home Phone (optional) Preferred Method of Communication - Select -Text MessageEmailPhone Call Best Time to Reach You Home Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Emergency Contact(s) Contact Information Contact Information Name Relationship to Student Phone Child Pick-Up & Transportation After tutoring sessions, my child will Be picked up by parent/guardian Walk home Drive themselves Be picked up by another authorized individual If applicable, please list names of individuals authorized to pick up your child: Please list anyone who is NOT authorized to pick up your child: Scheduling & Availability This information helps us determine your preferred availability and match your student with an appropriate tutor. Checking these times does not commit you to a tutoring session. Final session scheduling will occur once your student has been accepted. Preferred Start Date How many tutoring sessions per week would you prefer? 1 Session Per Week 2 Session Per Week 3 or More Sessions Per Week Weekly Availability Please check all times the student is available for tutoring Tuesday 4:00–5:00pm 5:00-6:00pm 6:00–7:00pm 7:00–8:00pm None of the above Wednesday 3:00–4:00pm 4:00–5:00pm 5:00-6:00pm 6:00–7:00pm 7:00–8:00pm None of the above Thursday 4:00–5:00pm 5:00-6:00pm 6:00–7:00pm 7:00–8:00pm None of the above Additional Scheduling Notes or Conflicts Medical Why we request this information? Agreement to the Medical Authorization and Summer Camp/Youth Programs Release (see link below) is required for participation in UNI Summer Camp/Youth Programs. The purpose of requesting medical information is to provide a safe and positive experience for our participants. Individual medical information questions are optional, please provide all of the information that will assist us to address the health and well-being of you or your child. Name of Family Physician (optional) Phone Number of Family Physician (optional) Is your child currently taking any medications? (optional) Does your child have any allergies? (optional) Does your child need disability accommodations during the tutoring session? (optional) I have read and agree to the University of Northern Iowa Release Indemnification and Medical Authorization Agreement. Read the Release Indemnification and Medical Authorization Agreement Agreement to the authorization and release are required to participate in this program. Photographs/Videotapes The EdVantageUNI Tutoring Program may photograph and/or videotape program activities throughout the semester that may include your child. These images or recordings may be used for educational, promotional, or program-related purposes.The image release is page 2, first paragraph of the Release Indemnification and Medical Authorization Please indicate your preference below I DO Approve the use of photographs/videos of my child for promotional and program-related purposes. I DO NOT Approve the use of photographs/videos of my child for promotional and program-related purposes. Please be sure to press the Submit button to complete your registration. Once submitted, you will be directed to a confirmation page. Leave this field blank
