Tutoring Program at Streams | Grand Rapids, MIStreams

Full Name of Person Completing this Form*

Relationship to Student*

Student's Full Name*

Student's Date of Birth*

Student's Gender*

Primary Language Spoken in the Household*

Other Language

If you chose "other" for primary language please write what primary language is spoken in the household.

Race/Ethnicity*

Student's Grade*

Does your household receive any type of government benefits such as SNAP, WIC, Social Security, Medicaid Etc.?*

Does this student have an active IEP?*

IEP (Individualized Education Plan)

Is this student a part of an ELL program at school?*

ELL (English Language Learners)

School*

Other School

If you chose one of the "other" options or your student's school was not listed in the previous question, please write the name of the school below.

Teacher's Name

Teacher's Email

Parent / Guardian's Full Name*

Parent / Guardian Email*

Student's Home Address*

Street Address City State ZIP Code

Parent/Guardian Marital Status

Parent / Guardian Phone*

Emergency Contact's Full Name*

Emergency Contact Phone*

Does your student have any allergies or medical conditions?*

If yes, please explain:

Please share what specific areas your student is in need of extra help. You may also share any other information you feels would be helpful for us to better understand your student's needs.

Tutoring Assessments

The consent below refers to the permission to administer educational assessments on students. Please read the attached waiver and then answer the consent below. (Copy and paste the link in a new tab to read the waiver.) Any additional questions regarding the assessments can be emailed to sue@streamsgr.org

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:0dd80382-1ad0-4fda-8b0a-94b860889ed6

Tutoring Assessment Consent*

*I hereby grant permission to Streams of Hope to administer standardized reading and math assessments through Stanford University on my child. I understand that this is optional and done to help provide data for Streams programming as well as information with regards to best tutoring approach for my child. I have read the waiver of consent and understand what I am agreeing to.

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Application Form

General Consent

The consent below details the guidelines and stipulations required to participate in a Streams program.

Consent*

*I understand that participation in this program is entirely voluntary. By signing this form, I acknowledge that I am choosing to participate in the program and am not being coerced or pressured in any way

*I understand that I am expected to conduct myself in a respectful and orderly manner. Management reserves the right to remove me or my child from any program based on misconduct.

I also hereby grant permission to Streams of Hope and its representatives to take photographs or videos of me, and/or my child while at Streams of Hope located at 280 60th St SE, Grand Rapids, MI 49548. I further grant producers and their representatives the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of these images and recordings in any media now known or later developed. I acknowledge that Streams of Hope owns all rights to the images and recordings.

I hereby waive any right to inspect or approve the use of the images or recordings or of any written copy. I also waive any right to royalties, or other compensation arising from or related to the use of the images, recordings, or materials. I hereby release, defend, indemnify, and hold harmless the producers from and against any claims, damages, or liability arising from or related to the use of the images, recordings, or materials, including but not limited to claims or defamation, invasion of privacy, or rights of publicity or copyright infringement, or any misuse, distortion, blurring, alteration, optical illusion or use in composite form that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I consent.

Parental Consent

If you are the child's parent/guardian, please submit your consent below. If not, leave blank.

*I understand that while participating in any program at Streams of Hope that my child is expected to conduct himself/herself in a respectful and orderly manner. Failure to do so could result in removal from the program at the discretion of management.

*I understand that participation in this program is entirely voluntary. By signing this form, I acknowledge that I am choosing for my child to participate in the program and am not being coerced or pressured in any way

*I am the legal parent/guardian of this student and do hereby consent and allow Streams of Hope, Grand Rapids, MI to handle any type of medical care for my child including but not limited to the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is in the care of Streams of Hope and I am not reasonably available by telephone to give consent.

*I also hereby grant permission to Streams of Hope and its representatives to take photographs or videos of me, and/or my child while at Streams of Hope located at 280 60th St SE, Grand Rapids, MI 49548. I further grant producers and their representatives the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of these images and recordings in any media now known or later developed. I acknowledge that Streams of Hope owns all rights to the images and recordings.

*I hereby waive any right to inspect or approve the use of the images or recordings or of any written copy. I also waive any right to royalties, or other compensation arising from or related to the use of the images, recordings, or materials. I hereby release, defend, indemnify, and hold harmless the producers from and against any claims, damages, or liability arising from or related to the use of the images, recordings, or materials, including but not limited to claims or defamation, invasion of privacy, or rights of publicity or copyright infringement, or any misuse, distortion, blurring, alteration, optical illusion or use in composite form that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I consent.

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Date

Tutoring Application

Thank you for your interest in this program.

Please submit an inquiry by completing the form below.

Tutoring Assessments

General Consent

Parental Consent

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