AM Pathways to Success Student Interest Form
Student Demographic Form
Last Name
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First Name
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Email
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Student First Name
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Student Last Name
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Student Date of Birth
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Telephone Number
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Street Address (No PO Boxes)
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Zip Code
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Preferred Method of Communication
Child's First Name
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Child's Last Name
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Child's Grade Level
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2nd
3rd
4th
5th
Other
School
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County
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Subject(s)
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Math ($175/12 weeks)
ELA ($175/12 weeks)
Both ELA and math ($300/12 weeks)
Upload Recent Report Card-We must have a current report card on file in order to approve your application to determine there is an academic need
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PDF, JPG, PNG, GIF, or WEBP · up to 25 MB
Special Accommodations
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IEP
504
N/A
Household Size
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How would you describe your child's current academic performance?
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Annual Household Income
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Does your household currently receive any of the following? (Free/Reduced Lunch, SNAP, TANF, Medicaid)
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Free Lunch
Reduced Lunch
SNAP
TANF
Medicaid
None
Please provide proof of benefits, a benefit letter or the first page of your W2.
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PDF, JPG, PNG, GIF, or WEBP · up to 25 MB
Race/Ethnicity
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Gender of your student
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What are your available days to tutor from 4pm-7pm? Please select all available days.
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Monday
Tuesday
Wednesday
Thursday
Are you able to commit to at least 2 days of consistently tutoring weekly?
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How did you hear about this program?
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Facebook
Instagram
LinkedIn
Google
Tabernacle Baptist Church
Referral (Please list the name of who referred you on the Other line)
My Child's School (Please list your child's school on the Other line)
Other
Would you like to apply for our partial scholarship, if available? (Eligibility based on Family size/income and current academic need with a C or below)
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Do you understand that this program is not a homework help program? We are an intervention based program that focuses on closing educational gaps.
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Submit