New Student Application

Student's Information
Student's First Name*
Student's Last Name*
Students Grade*
School*
Gender*
- Male
- Female

Your Information
Your First Name*
Your Last Name*
Cell Phone*
Email Address*
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Student*
Mother, Grandmother, Uncle, etc
Emergency Contact
Please list someone else other than the parent/guardian identified above.
Your First Name*
Your Last Name*
Phone Number*

PARENT/GUARDIAN STATEMENT

______________________________ (student's name) has my permission to attend the Cluster Tutoring Program. I have received a copy of the Parent Handbook and understand the policies and procedures of the program. I agree to work with my child's tutor and Cluster in order to ensure productive tutoring sessions.

Cluster and my child's tutor have my permission to contact the child’s teacher to discuss his/her academic needs. I agree to supply Cluster with a copy of my child's report card and standardized test scores. I give Cluster permission to share that information with my child's tutor.

I understand that Cluster serves nut products for snacks and agree that it is my responsibility to notify Cluster staff in writing if the child is allergic to any substance.

I acknowledge that Cluster bears no responsibility or liability for tutor-student contact or activities occurring outside of the program's Tuesday and Thursday evening tutoring sessions and that any such contact or activities are not part of the tutoring program provided and administered by Cluster. Students are not to accept rides to or from Cluster from a volunteer and I acknowledge that Cluster bears no responsibility or liability for any loss, damage or injury resulting from such unauthorized transportation of students.

Cluster and its partners have my permission to use any photographs of, quotes from, art work or written work by in their grant proposals, promotional materials, newsletter, web site, etc.
Signature

Step 1 of 4

Student's Information

Your Information

Emergency Contact

The following question is for grant reporting purposes.

We request the following information in order make a better match for the student and prepare the tutor:

PARENT/GUARDIAN STATEMENT

Contact Information

QuickLinks

Step 1 of 4

Student's Information

Your Information

Emergency Contact

The following question is for grant reporting purposes.

We request the following information in order make a better match for the student and prepare the tutor:

PARENT/GUARDIAN STATEMENT

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Contact Information

QuickLinks