New Student Application

Step 1 of 4

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

Your Information
Your First Name*
Your Last Name*
Cell Phone*
Email Address*
Address*
Street Address City State ZIP Code
Relationship to Student*

Mother, Grandmother, Uncle, etc
Emergency Contact
Please list someone else other than the parent/guardian identified above.
First Name*
Last Name*
Phone Number*

PARENT/GUARDIAN STATEMENT

The student identified in this application has my permission to attend the Cluster Tutoring 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 it is my responsibility to notify Cluster staff in writing if the student is allergic to any food or substance.

I acknowledge that Cluster bears no responsibility or liability for tutor-student contact or activities occurring outside of the program's Monday, 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.

I acknowledge the contagious nature of the COVID-19 virus and acknowledge that the Cluster Tutoring Program adheres to the CDC recommendations of practicing social distancing and wearing face coverings. I further acknowledge that no guarantee exists regarding whether or not my child may contract COVID-19. I understand that the risk of becoming exposed to and/or infected by the COVID-19 virus may result from the actions, omissions, or negligence of myself and others, including but not limited to, paid staff, volunteers and others. I acknowledge that I may increase my child’s risk of exposure to COVID-19 by participating in Cluster Tutoring activities. In the event a participant tests positive for COVID-19 within Forty-Eight (48) hours of the activity, I hereby waive confidentiality and authorize Cluster Tutoring to disclose this information to other program participants. I agree that I will not send my child to an in-person tutoring session if they are experiencing any symptom of illness such as cough, shortness of breath, difficulty breathing, fever, chills, muscle pain, headache, sore throat, or new loss of taste or smell.

I hereby release and agree to hold the Cluster Tutoring Program, its Board Members, employees, and volunteers harmless from any causes of action, claims, demands, damages, costs, expenses, and compensation for damage to myself or my children that may be caused by any act, or failure to act, or that may otherwise arise in any way while I am participating in Cluster Tutoring activities. I fully understand that this release discharges the aforementioned from any liability with respect to bodily injury, illness, death, medical treatment, or in connection to my child’s participation as described above.
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