Tutoring Referral - Tidewater Friends of Foster Care

Name of Person Completing This Form*

First Last

Tutoring Requests require a consent to be submitted by the legal guardian or the consent of an adult participant over 18 years old. This consent can be submitted subsequent to this request.

Email*

Phone*

Relationship to Student*

Self (student 18+)
Social Worker / Legal Guardian
Other (Foster Parent, TFC Worker, Relatives)

Explain your relationship to the student

Social Worker / Guardian Name*

First Last

Social Worker / Guardian Email*

Tutoring Guidelines

• A Responsible Adult must be present for all tutoring sessions and is responsible for providing a suitable work environment, as well as materials and supplies. • Cancellation or rescheduling of a session requires 24-hour notice to the tutor, otherwise the session is reported as a No Show to the Social Worker. • Upon return home or adoption, enrolled students remain eligible for tutoring through the end of the academic year and one additional academic year. • Following each Tutoring Session, a Session Report is completed by the tutor and TFFC provides this report to the Social Worker and a session summary to the caregiver.

Acknowledgements:*

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One-on-one instruction in the student’s home will begin approximately 2 weeks from referral submission (except for students just entering care, which takes approximately 4 weeks). NOTE: Due to COVID virtual tutoring is offered (please select your preference below).
I have notified the parent/caregiver that the Student has been referred for tutoring services through TFFC and discussed scheduling availability.
Upon three (3) No Shows, TFFC will suspend tutoring services and the Social Worker will be asked to call a Family Team Meeting to address attendance issues before services can be resumed.

Please read and acknowledge by clicking the boxes.

Tutoring Guidelines for Students over 18

• As an Adult Student, you 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 the session is reported as a No Show to the Social Worker. • Following each Tutoring Session, a Session Report is completed by the tutor and TFFC provides this report to the Social Worker by email.

Acknowledgements:*

Select All
One-on-one instruction in the student’s home will begin approximately 2 weeks from referral submission (except for students just entering care, which takes approximately 4 weeks). NOTE: Due to COVID virtual tutoring is offered (please select your preference below).
Upon three (3) No Shows, TFFC will suspend tutoring services and the Social Worker will be asked to call a Team Meeting to address attendance issues before services can be resumed.

Please read and acknowledge by clicking the boxes.

Student Information

We will collect the remaining information from the Caregiver/Guardian once you have submitted the form.

Hidden

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 this client to have in-person tutoring and opt for virtual tutoring only.

Please read and acknowledge by clicking the appropriate box:

COVID WAIVER:*

I understand the risks associated with contracting COVID-19 and consent to in-person tutoring.
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

Student's Date of Birth*

Student's Current Age*

Please enter a number greater than or equal to 0.

Are you who we should Contact to Coordinate Tutoring Sessions?*

Yes
No

Who should we contact to coordinate tutoring sessions? (POC)*

First Last

Phone for POC*

Email of POC*

Student's Home Address OR Location of Tutoring*

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

School*

Grade Level*

Area(s) of Need*

Does your youth have access to a computer?*

Yes
No

TFFC is now implementing baseline, interim and end of year assessment for all tutoring clients so we can measure progress. These test are done through IXL, an internet based learning platform. Please let us know if your youth requires access to a computer or if they have access to one at home.

Does your youth require supervision for the use of electronics?*

Yes
No

During the course of your youth's tutoring they will be taking online assessments. Please let us know if they are not otherwise allowed to use electronic devices and will require the direct supervision of their tutor or parent/caretaker while taking these assessments.

Days/Times Available for Tutoring*

Describe any Special Requirements for Tutoring

Reading Proficiency Issues?

Opt in for additional Reading support

Please let us know if your student is more than 2 levels behind in reading and would benefit from additional Reading Support.

Emotional Stability*

I confirm student is physically and emotionally stable enough for weekly tutoring services.

Ready for Tutoring?*

I confirm that I am physically and emotionally prepared for weekly tutoring services.

Is there an IEP or a 504 plan in place?*

Yes
No
Not sure

Upload a copy of the IEP or 504

Drop files here or

Max. file size: 40 MB.

CONSENT TO EXCHANGE INFORMATION ON STUDENT

As the Legal Guardian, I understand that Tidewater Friends of Foster Care, Inc. (TFFC) provides services and benefits to youth in my guardianship. TFFC must have specific information to provide services and benefits. By signing this form, I am allowing TFFC to exchange certain information so it will be easier for them to provide or coordinate these services or benefits.

Legal Guardian's Name*

First Last

Legal Guardian's Agency*

If no Agency, please put N/A.

Legal Guardian's Address*

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

I want the following confidential information about the Student to be exchanged with Tidewater Friends of Foster Care, Inc. - 999 Waterside Dr., Suite 430, 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.

As the Legal Guardian, I consent to allow Tidewater Friends of Foster Care to exchange the selected information to provide or coordinate services or benefits.

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*

Consent to Exchange Information for Students 18+

I understand that Tidewater Friends of Foster Care, Inc. (TFFC) provides educational services and benefits and that TFFC must have specific educational information to provide such services. By signing this form, I am allowing TFFC to exchange certain information with my school so it will be easier for them to provide or coordinate these services or benefits.

I want the following confidential information to be exchanged with Tidewater Friends of Foster Care, Inc. - 999 Waterside Dr., Suite 430, 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.

As an adult student, I consent to allow Tidewater Friends of Foster Care to exchange the selected information to provide or coordinate services or benefits.

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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Phone

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

Tutoring Referral for Foster Youth

Tutoring for Foster Youth

Tutoring Guidelines

Tutoring Guidelines for Students over 18

Student Information

CONSENT TO EXCHANGE INFORMATION ON STUDENT

Consent to Exchange Information for Students 18+

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