Noto

M.A.P.L.E. Tutoring Application

We are an open-enrollment school. Students may join our tutoring program anytime throughout the school year based on available space.

Here's what to expect:

Your responses will be kept confidential.
A Samara staff member will reach out to discuss specifics.

Today's Date*

Child/Student First Name*

Child/Student Last Name*

Child/Student Date of Birth*

Gender Pronouns preferred*

Primary Address:*

Ethnicity*

African America

Asian America

Indigenous American

Latino/Hispanic

White

Other:

Decline to State

What is your child's primary language?*

Please list other languages spoken at home.

What type of service(s) are you looking for from Samara?*

1-on-1 tutoring

small group tutoring/homework help

1-on-1 tutoring with a learning specialist

Other

If 'Other' please specify

First Name*

Last Name*

Relationship*

Address (if different from child's)

Marital Status *

Phone Number*

Email*

Full Name/ Relationship

Address (if different from child's)

Marital Status

Contact Information (phone number, e-mail)

Additional Emergency Contact(s): please include name and phone number

Please list additional person(s) authorized to collect your child from Samara. (Parents/Guardians and emergency contacts are considered authorized unless noted otherwise.)

Describe your child's personality*

Please describe your child's favorite activities/interests*

Please describe your child's strengths and weaknesses*

How does your child communicate that they are frustrated or need a break?*

Name of current school:

Type of school:

Grade *

Does your child have an IEP or 504 goals?*

Has your child been evaluated through their school?*

If your child has been evaluated, please list the name of the school, areas evaluated, and date(s)?

How would you describe your child's learning style?*

Please describe your child's current struggles:*

Please describe your child's current strengths*

What are some things your child struggles with or avoids (situations, games, topics, sensory input, etc.)?*

How do you hope the Samara Learning Center can help your child?*

Please describe your child's current health:*

List any known allergies your child has:*

Please list any medications that might affect your child during tutoring

Does you child have any vision or hearing limitations?

What else do you want us to know about your child?

How did you hear about Samara Learning Center?