SMART Application - Tutoring Chicago

Complete one application for each student you want to enroll in the program.

Please have the following information ready while completing this application:

Student’s school information
Student’s academic needs
Emergency contact information

During the 2022-2023 school year, Tutoring Chicago will be offering both in-person and digital tutoring options to our students. Within this application you will have an opportunity to tell us more about your student’s needs and preferences. Our staff will do our best to accommodate the preferences of our students but in some cases we may not be able to accommodate all preferences due to limited capacity of physical space or volunteer availability.

If your student is applying to Tutoring Chicago for the first time, they must be in 1st-6th grade. Tutoring Chicago will not accept any new applicants in grades 7th, 8th, or 9th.

Is this application for a new or returning student?

New Returning

Who was this student’s Tutoring Chicago program manager during the 2021-2022 program?

How long has the student been enrolled in Tutoring Chicago?

Parent/Guardian Information

Parent/Guardian First Name	Parent/Guardian Last Name
Relationship to student	Street Address Tutoring Chicago may occasionally need to mail you items (holiday gifts, tech equipment, books, etc.). Please be sure to include an up to date address with apt/unit # if applicable.
Apartment/Unit #	City
State	Postal Code
Email	Phone
Alt Phone	Tutoring Chicago routinely sends texts and email updates about our programs to families. Please select which language in which you would like to receive these updates. EnglishSpanish

The following information MUST BE DIFFERENT than parent/guardian.

Emergency contact Full Name

First and Last name required

Emergency contact Phone

Relationship to student

Policies

Digital and In-Person Permission:

I understand that Tutoring Chicago is offering both in-person and digital tutoring options during the 2022-2023 school year. I understand that Tutoring Chicago will do its best to accommodate my preferences but may not be able to in all cases. I understand that my child will be expected to connect on time either digitally via Zoom or in-person at one of our locations with their assigned tutor, working on academic enrichment once a week.

I recognize that Tutoring Chicago will provide a schedule, guidance, resources and best practices for these sessions. I understand that it is my responsibility as a parent/guardian to supervise and facilitate any digital contact between my child and their tutor (video conferencing, emails, FaceTime, phone, texts, etc).

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General Permission

I give permission for my child to be enrolled in the Tutoring Chicago program. I understand the program is a service to my child and that my child may be dismissed at any time. If my child is to remain enrolled, he or she must attend each session and follow the rules. I understand that attendance is essential to my child’s improvement. I will inform the tutor and a Tutoring Chicago staff member if my child is going to be absent. I recognize that tutoring is a resource not to be taken away as a form of punishment.

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Academic Data

I permit Tutoring Chicago and my child’s tutor to contact my child’s school, teacher(s), counselor(s), administration, and/or school system to attain specific information about my child’s academic performance and needs including, but not limited to, report card grades, standardized test scores, homework scores, academic strengths and weaknesses, social/emotional well-being, and general classroom performance. I understand that this information may be shared with my child’s tutor in order to aid the learning process. I understand that this information will be housed in Tutoring Chicago’s database and viewable by Tutoring Chicago staff and third party consultants for data analysis purposes.

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Medical Emergency

In the event of a medical emergency, I grant permission for my child to be transferred to a medical facility for treatment and receive the treatment deemed necessary by the qualified medical staff at that site. I will be responsible for all costs incurred with such treatment(s). I understand that in the event of such an emergency, Tutoring Chicago will make all reasonable attempts to contact the parent/guardian or emergency contact I have listed on this application. In consideration of being permitted to participate, I do hereby waive and release Tutoring Chicago and all affiliates, directors, employees and volunteers from any and all claims for injuries, including death, damages, property damage, or loss which may occur on account of participation in the tutoring program, including field trips and special events.

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Health and Safety / COVID-19 I agree that myself and my child will comply with any health and safety policies and procedures put in place by Tutoring Chicago or our partner facilities. I understand that Tutoring Chicago will make these policies known and available in the parent handbook and in ongoing communication updates that will be sent to me. I understand that Tutoring Chicago will continue to monitor and assess safety risks and follow the guidance of our in-person facilities and local health officials. I agree to inform my program manager if my student is not feeling well and keep them home from tutoring. I understand that if my student is too sick to attend school, they should be kept home from tutoring. I understand that if my student or someone they have had close contact with tests positive for COVID-19, I must report it to my program manager. By submitting this form, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my student may be exposed to or infected by COVID-19 by their mere presence during scheduled tutoring sessions and that such exposure or infection may result in their injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of my student and others, including, but not limited to, employees, volunteers, and other program participants and their families. I hereby release Tutoring Chicago from any and all claims arising from or in connection with any direct COVID-19 impact while my student is participating in their weekly tutoring sessions. I attest that all information in this form is true.

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Off-site Contact TUTORING CHICAGO neither encourages nor endorses in-person, off-site independent contact and activities between students and tutors. If such relationships and/or activities are to take place independent of a tutoring session, TUTORING CHICAGO is not responsible for accidents and/or incidents arising from such events.

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Media Release I permit Tutoring Chicago to use any photographs or video footage featuring my child or any artwork, writings, or media statements taken or created in connection with the program for any type of publicity or fundraising without requiring further approval. I understand that Tutoring Chicago may publicize my child’s first name, initial of their last name, and grade, but will not include their full last name or any other identifying information without parent/guardian advanced approval.
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Privacy Tutoring Chicago’s privacy policy can be viewed here. I permit and understand the following privacy policies as it relates to information I submitted in this application:

Tutoring Chicago will share necessary information with my child’s tutor including; name, age, grade, gender, parent/guardian phone and email as well as any information contained on the school information page of this application. Tutoring Chicago will print my child’s allergies and/or asthma condition on his/her/their nightly name tag for my child’s health and safety. Any additional information I shared about my child’s health may be shared in confidence with my child’s tutor but will not be displayed on a name tag. All other information contained within this application is considered confidential and will only be accessible to Tutoring Chicago staff.

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Financial and Legal Information

I certify that all legal and financial information in this application is correct and I can provide verification if requested. I understand that this information is confidential and will only be accessible to Tutoring Chicago staff for the purpose of verifying my child’s eligibility for the program.

Type full first name

Does your student receive English Learner (EL) services? YesNoI don’t know	Is your student in a dual language or bilingual classroom? YesNo
If yes, please describe: ex. student has homework in Spanish	Does your student have an Individualized Education Program (IEP)? YesNoI don’t knowDecline to answer
If yes, please choose which of these best describes your student:	If yes, please describe your student’s IEP:
Does your student have a 504 Plan? YesNoI don’t knowDecline to answer	If yes, please describe your student’s 504:
Does your student demonstrate any issues with behavior that their tutor should be aware of? YesNo	If yes, please describe your student’s behavior:
What subject(s) does your student need the most help in? MathReading	Based on communications from school, is your student reading at grade level?

Student Application 2022-2023

Parent/Guardian Information

The following information MUST BE DIFFERENT than parent/guardian.

School Information

Health Information

Family Financial Information

Policies

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