TFFC Tutoring For All Request - Tidewater Friends of Foster Care

Individual Completing Tutoring Form*

First Last

Email*

Phone*

Relationship to Student*

Tutoring Guidelines

• A Responsible Adult must be present for all tutoring sessions. Parents are responsible for providing a suitable work environment, as well as materials and supplies. • Cancellation or rescheduling of tutoring sessions requires 24-hour notice to the tutor, otherwise a session will be charged against the account. • Following each Tutoring Session, a Session Report is completed by the tutor, which is provided to the parent.

Student Information

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COVID WAIVER:

I understand the risks associated with contracting COVID-19 and as the legal guardian consent to in-person tutoring for this student.
I do not want to have in-person tutoring and opt for virtual tutoring only.

Please read and acknowledge by clicking the appropriate box:

Student's Name*

First Last

Date of Birth*

Gender*

Student's Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

School*

Grade Level*

Area(s) of Need*

Days/Times Available for Tutoring

Describe any Special Requirements for Tutoring

Is there anything else you would like us to know?

SOCIAL SERVICES: Does this student have lived experience in the foster care system or involvement with child protective services?

Yes
No

Scholarships for youth with Social Services involvement

If the student applicant has lived experience in the foster care system or involvement with CPS within the TFFC service region, they may be eligible for a grant-sponsored scholarship. Please provide the household demographic information below to qualify. Rest assured, we will not release your personal information. We collect this information for funding eligibility and are obligated to release an annual aggregated report on grant funding allocation (for example, the number of households we served relative to income level). If you receive a subsidy for tutoring, you are agreeing to provide your child's report card (and IEP/504 if applicable ) by giving TFFC consent to exchange information with your child's school. You are also giving TFFC consent to track your child's academic progress. If you have any questions about how we use this data, or would like to receive a copy of our demographic report, please contact us at info@tidewaterffc.org.

Number of Household Members

Please enter a number greater than or equal to 1.

Number of Household Members UNDER 18 years old

Please enter a number greater than or equal to 0.

Household Income

Select an annual household income bracket below.

I want the following confidential information about the Student to be exchanged with Tidewater Friends of Foster Care, Inc. - 999 Waterside Dr., Suite 103, Norfolk, VA. 23510 Phone: 757-227-4187 Fax: 757-561-0979 Email: tutoring@tidewaterffc.org*

Select All
Grades, Progress Reports and Report Cards
IEPs, 504 plan, DRAs & SOLs
Verbal & written communication with student's academic team
Assessment Information

This information will be exchanged ONLY for the purpose of Service Coordination for the TFFC Academic Tutoring Program.

Period of Consent*

I can withdraw this consent at any time by notifying Tidewater Friends of Foster Care. This will stop all Schools/Agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about has been shared, and why, when, and with whom it was shared. If I ask, Tidewater Friends of Foster Care will show me this information.

Consent

I agree to the above Exchange of Information.

Electronic Signature*

By selecting CONSENT box and Typing my Full Name above, I confirm my consent and understand that I am electronically signing this form.

Today's Date*

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Email

This field is for validation purposes and should be left unchanged.

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