New Student Application Step 1 of 4 25% Student's InformationStudent's First Name*Student's Last Name*Students Grade*School*Gender*MaleFemale Your InformationYour First Name*Your Last Name*Cell Phone*Email Address* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship to Student*Mother, Grandmother, Uncle, etcEmergency ContactPlease list someone else other than the parent/guardian identified above.Your First Name*Your Last Name*Phone Number* Availability*Student would like to come to Cluster on TUESDAY evenings in Chicago.Student would like to come to Cluster on THURSDAY evenings in Oak Park.The student can come to Cluster on either Tuesday or Thursday evenings.What areas does the student need to work on this year?* Math Advanced Math Reading Writing Science Social Studies Other Check all that applyWhat Topics In Math? Addition, subtraction Multiplication, division Fractions The following question is for grant reporting purposes.The answer does not affect a student’s eligibility for the program:Does the student qualify for free or reduced lunch at his or her school?*YesNoWe request the following information in order make a better match for the student and prepare the tutor:Does the student have an Individual Education Plan (IEP), 504, or Title I?*YesNoWhat is the IEP, 504 or Title 1 service for?Does the student have a learning disability?*YesNoPlease describe 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 This iframe contains the logic required to handle Ajax powered Gravity Forms.