We work with children from low-income households. Will you be able to provide documentation of annual income or proof of assistance from programs such as SNAP, TANF, CHIP, Medicaid, or AFDC?
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Yes
No
Is your child reading below grade level?
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Yes
No
Parent/Guardian Name
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First Name
Last Name
Parent Phone
*
(###)
###
####
Parent Email
*
What is the best way to reach you?
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Email
Text
Call
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child's Name
*
First Name
Last Name
Please phonetically spell your child's name (optional).
Your child must be in grades 3-8. Please tell us which grade your child is in.
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3rd
4th
5th
6th
7th
8th
Child's Birthday
*
MM
DD
YYYY
Child's Gender
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Girl
Boy
Non-Binary
Prefer to self-describe in another way not listed
Prefer not to say
Child's Race/Ethnicity
*
This demographic information is helpful for funding purposes. Please check all that apply.
We occasionally publish photos of students and tutors on our website, on social media, and various communications materials like email campaigns. Do you consent to your child's photograph being published?
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Yes
No
School Name
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Teacher's full name and email if available
Does your child have an IEP?
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Yes
No
Child's last known reading level (F&P, Lexile, any level or books they are currently reading).
*
What language(s) is(are) spoken at home?
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Please describe why you are seeking literacy tutoring for your child. (When did their reading issues begin? What interventions, if any, has your child received? Are reading issues affecting overall schooling?, etc.)
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Please tell us a little bit about your child (likes, dislikes, allergies or dietary restrictions?)
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How did you hear about READ 718?
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Today's Date
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MM
DD
YYYY
