ACACIA EDUCATIONAL SUPPORT SIGN-UP

2017-2018 School Year

If you are reading this, you consider education to be important. You have also realized that someone in your household needs additional support. In order to be of service, we need some information about the student seeking support. First, there are some forms to fill out. Click on the links below to print and complete these forms at home (we've provided both a Word document and a PDF version for each). Please bring these forms to your first meeting with an Acacia mentor.

 

Emergency Contact:  Word or PDF 

Student Questionnaire: Word or PDF 

Parent Questionnaire: Word or PDF

 

Next, we need to know when we can meet with your student and the subjects in which they need support. Complete all the information below to sign-up for an appointment to begin educational support. Someone will contact you to confirm the appointment. We will do our best to honor your choices based on mentor(s) who are available at those times.

 

* Required Fields

 

Student's Full Name: *
First Name
Middle
Last Name
Date of Birth:
Address:
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Parent/Guardian Name: *
First Name
Middle
Last Name
Primary Phone Number:*
Secondary Contact Phone Number:
Student Cell Number:
Contact Email:*
School District: *
School Name:*
Grade Level: *
Desired Start Date:*
Tuesday Student Availability - Please select all times the student could meet for tutoring on Tuesday:
Wednesday Student Availability - Please select all times the student could meet for tutoring on Wednesday.
Thursday Student Availability - Please select all times the student could meet for tutoring on Thursday:
Meeting Preference: *
Subjects you'd like help with:
Foreign Language Assistance (PLEASE INCLUDE CURRENT GRADE IN THE "OTHER" box so that we can track improvements):
Math Assistance (PLEASE INCLUDE CURRENT GRADE IN THE "OTHER" box so that we can track improvements):
Science Assistance (PLEASE INCLUDE CURRENT GRADE IN THE "OTHER" box so that we can track improvements):
History Assistance (PLEASE INCLUDE CURRENT GRADE IN THE "OTHER" box so that we can track improvements):
Communication Arts Assistance (PLEASE INCLUDE CURRENT GRADE IN THE "OTHER" box so that we track improvements):
Other subjects not noted above:
Study Skills:
Is there anything else that we should know which might help us in successfully tutoring your student?