Tutoring Request - Bio Parent - Tidewater Friends of Foster Care

Legal Guardian Name*

First Last

NOTE: The Consent for Information Exchange must be signed by the Parent or Legal Guardian.

Legal Guardian Email*

Legal Guardian Phone*

Who will be coordinating Tutoring Sessions?*

Legal Guardian
Another Adult (please provide name below)
School Site Coordinator

Tutoring Guidelines

• One-on-one instruction will begin approximately 2 weeks from referral submission. Virtual is an option and can be provided upon request (contact us for details). • Enrolled students remain eligible for tutoring through the end of the academic year. • Caregivers/Guardians are responsible for providing a suitable work environment, as well as materials and supplies. • Caregivers/Guardians may request a change of tutor if the relationship is not working for their student.

Acknowledgements:*

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One-on-one instruction will begin approximately 2 weeks from request submission.
Virtual tutoring is offered as an option (please contact us for details is this is preferred).
A Responsible Adult must be present for ALL tutoring sessions.
Cancellation or rescheduling of tutoring sessions requires 24-hour notice to the tutor, otherwise the session is considered a No Show.
Upon three (3) No Shows, TFFC will suspend tutoring services and a $25 must be submitted prior to reinstating the services.

Please read and acknowledge by clicking the boxes.

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COVID WAIVER:*

I understand the risks associated with contracting COVID-19 and consent to in-person tutoring. I assume all risks and liabilities associated with contracting COVID-19 as a result of in-person tutoring.
I do not want in-person tutoring and will continue with virtual tutoring only.

Please read and acknowledge by clicking the appropriate box: Tidewater Friends of Foster Care, Inc. has put in place Virtual Tutoring to reduce the spread of COVID-19. Participating in In-Person Tutoring provided by TFFC could increase your risk and your child(ren)’s risk of contracting COVID-19.

Student Information

Please provide the requested information on the student so we can provide services.

Student's Name*

First Last

Date of Birth*

Name Person Coordinating Tutoring Sessions*

First Last

This is the person who we will contact to coordinate tutoring.

Coordinator's Phone*

Coordinator's Email*

Student's Home Address*

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

Does this student have an IEP*

Yes
No
Not sure

Upload a copy of the IEP

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 my child. TFFC must have specific information to provide these services and benefits. By signing this form, I am allowing TFFC to exchange the information specified below so it will be easier for them to provide or coordinate these services or benefits. This consent will be provided to the school to allow exchange of information in support of tutoring services.

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Legal Guardian's Name*

First Last

Same Address as Student?*

The Student's Address is the Legal Guardian's Address
Legal Guardian does not live with Student

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 103, Norfolk, VA. 23510 Phone: 757-227-4187 Fax: 757-561-0979 Email: tutoring@tidewaterffc.org*

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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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Name

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

Caregiver Tutoring Request & Consent

Parent/Caregiver Tutoring Form & Consent to Release of Information

Tutoring Guidelines

Student Information

CONSENT TO EXCHANGE INFORMATION ON STUDENT

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