Chicago Lights Tutoring Student Application 2023-2024

Student's First Name

Student's Last Name

Street

City

State

Zip

Student's Gender or Gender Identity

If other, please explain:

Student Birth Date

If selected other, please answer:

PARENT/GUARDIAN INFORMATION

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Student

Parent/Guardian Email Address

Parent/Guardian Cell Phone

Parent/Guardian Work Phone

Parent/Guardian Home Phone

EMERGENCY CONTACT INFORMATION

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Relationship to Student

STUDENT CONTACT INFORMATION

Student Mobile

Student Email

STUDENT SCHOOL INFORMATION

School

Student's Grade in School Year 2023-2024

School Type

Teacher

If Applicable: CPS Student Email

If other, please explain:

Program Information

Choose one evening for your child to attend Tutoring. (Note: Mondays are ALL Virtual. For Tuesdays and Wednesdays, you can select IN Person OR Virtual attendance below.)

I would like my student to attend: (Note: Mondays are ALL Virtual. For Tuesdays and Wednesdays, you can select IN Person OR Virtual attendance here.)

Was your child in the program last year?

Would they like the same tutor?

If yes, what is the name of your student's tutor?

How many years has your child been in the Tutoring Program?

What is the student’s most recent report card grade in Reading? (If you do not know the grade, please estimate: ex. above average, average, or below average.)

What is the student’s most recent report card grade in Math? (If you do not know the grade, please estimate: ex. above average, average, or below average.)

Has the student repeated any grade levels?

If so, what grade(s)?

Is student enrolled in special education classes?

Does student have an IEP or 504 plan?

If Yes, what services/accommodations is your child receiving through his/her IEP/504 and what goals is s/he working on?

Does student have any health impairments?

If yes, please explain:

Is student currently on any medications?

If yes, please explain:

Does student have any dietary allergies or restrictions?

If yes, please explain:

What are your child’s strengths?

What are your child’s challenges?

When your child is frustrated, not focused, upset, sad, etc, what is the best way to help them work through those feelings?

What are your educational and/or social-emotional goals for your child?

What are your child's interests and hobbies?

Is your child eligible for free or reduced price lunch?

TRANSPORTATION

The Tutoring Program offers free bus transportation contracted by Ron’s Transportation to and from the program on Tuesdays and Wednesdays from the near north, near west and south side neighborhoods of Chicago at the following locations:

North Side

(4:35pm) MANIERRE SCHOOL (1420 N. Hudson)

(4:40pm) SEWARD PARK (Orleans & Division)

(4:45pm) ST. MATTHEW’S CHURCH (1000 N. Orleans)

West Side

(4:30pm) ST. MALACHY (Oakley & Maypole)

South Side

(4:30pm) MCCORMICK THEOLOGICAL SEMINARY (54th and University)

If those bus stops are not convenient for you, parents may also drop off and pick up their student, or if old enough, students may walk or use public transportation. Please Note: Participants of Chicago Lights Programs who are under the age of 18 are prohibited from using ride sharing services, such as Uber and Lyft, as transportation to and from the program. If the parent/guardian is unable to transport the participant to and from the program, please do not send the participant to the program on that day. Additionally, volunteers and staff of Chicago Lights are not permitted to chaperone students on any ride sharing service.

Please select how your student will get TO the Tutoring Program:

If selected Tutoring Bus Service, please select which stop:

Please select how your student will LEAVE from the Tutoring Program at the end of the evening:

If selected Tutoring Bus Service, please select which stop:

Please Note: Students using these bus stops will participate in In2it Café which includes dinner and an arts activity before Tutoring. All students must wear their seat belts while riding the bus.

After tutoring, students will be dropped off between 7:45 pm and 8:00 pm at the bus stops listed above.

You MUST stay with your child until the bus arrives and you MUST be present when your child is dropped off in the evening.

The following transportation program release form MUST BE SIGNED by a parent for any student who uses the Tutoring bus service, provided by Ron's Transportation, Inc. After reading, YOU MUST enter your name.

I give permission for my child to use the Tutoring bus service, provided by Ron's Transportation. for the purpose of transportation to and from the Tutoring Program. I hereby release Fourth Presbyterian Church and Chicago Lights from any liability and assume full responsibility for the safety of my child at all times. I recognize that Fourth Presbyterian Church and Chicago Lights are not responsible for my child while walking to or from the designated bus stops. I understand that Fourth Presbyterian Church and Chicago Lights will utilize all reasonable safety precautions.

By typing my name below, I agree to the above Transportation Release.

Full Name

Date

PARENT/GUARDIAN WAIVER and ACADEMIC RELEASE

I understand, that while Fourth Presbyterian Church and Chicago Lights will utilize all reasonable safety precautions, I release Fourth Presbyterian Church and Chicago Lights from any liability and assume full responsibility for my child at all times.

I understand that Chicago Lights and Fourth Presbyterian Church neither endorses nor sponsors off-site, independent relationships and activities between volunteer tutors and students. If such relationships and/or activities occur independent of the on-site tutoring sessions, Chicago Lights and Fourth Presbyterian Church are not responsible for accidents and/or incidents arising from such events. Volunteers and parents/guardians of students are responsible for communicating directly with each other to navigate offsite relationships, using all reasonable safety precautions including, but not limited to: initial volunteer and parent/guardian meeting, volunteer obtaining written permission from the parent/guardian of the student for any off-site outing, and volunteer and parent/guardian agreeing to and planning outings in public, safe environments.

Furthermore, I hereby grant permission to the above named teacher/school to share academic information with my child’s Chicago Lights Tutoring Program Tutor and the Chicago Lights Tutoring Program management staff. This information may include, but is not limited to, homework assignments, grades and report cards, test results, vision/hearing testing, and Individualized Education Plans. This information may be shared verbally or in writing.

This release is valid for the current 2023-2024 school year and can be rescinded, through written request, at any time.

By typing my name below, I agree to the above Waiver and Academic Release.

Full Name

Date

PHOTOGRAPHY AND VIDEO

The staff of Chicago Lights and Fourth Presbyterian Church periodically take photographs and video of our volunteers, students, staff, and student artwork and writing for use in celebrating and promoting the Tutoring program. These images are our most compelling representations of Tutoring and are vital to our effort to generate funding to support the program. These photographs, videos, and student work, which are used in print pieces and electronic communications, are used only by Chicago Lights and Fourth Church. They are never sold, nor are they used by other individuals or organizations without permission from those in the images. Similarly, no individuals in the images are ever identified by name without their permission. Do you grant permission for Chicago Lights and Fourth Presbyterian Church to photograph or film your child and use such photos, videos, or student work in these ways to depict the work of the Tutoring program?

Please select one option below:

USE OF TECHNOLOGY

I understand that the use of cell phones, tablets, laptops, social media, or any other device considered technology during Chicago Lights Tutoring Program is NOT ALLOWED unless for academic reasons or communication with parents. I also understand that if my child is using any type of technology device, social media, or app not for academic reasons, it will be confiscated for the night. It will be returned at the end of programming. I also understand that Chicago Lights is NOT responsible for the loss or damage of any devices on Chicago Lights or Fourth Presbyterian Church property. In the event of an emergency, the parent or guardian may contact staff or the reception desk.

By typing my name below, I agree to the above statements:

TWO WAY PLEDGE

Tutoring Program Staff Pledge: We understand the importance of the Tutoring experience for every student and our role as caring educators. Therefore, we agree to carry out the following in partnership with you:

Provide a safe place for your child to learn and try new activities.
Assign your child a one-to-one tutor/mentor to assist with homework and other activities
Maintain an open-door policy for parents, welcoming you to call or come to Tutoring at any time to observe the program, meet your child’s tutor, or meet with program staff.
Strive to be aware of your child’s individual needs.
Communicate with you regarding your child’s progress and behavior, when necessary.

Parent/Guardian Pledge: Parents and family are a child’s first and most important teachers. To encourage my child’s learning and success at Tutoring, I will do the following:

Ensure that my child follows all program expectations and policies and encourage my child to participate fully in all activities when at Tutoring.
Be present with my child at the bus stop, during pick-up and drop-off for Tutoring, on time, each week.
Make sure my child gets plenty of rest.
Recognize that Tutoring is a resource not to be taken away as a form of punishment.
Make every effort to ensure my child’s regular, weekly attendance at Tutoring from October - May.
Understand that after three unexcused absences my child may lose his/her spot in the program.
Call Mark at 312.274.3828 to report my child’s absences.
Develop a relationship with my child’s tutor/mentor via phone, text, e-mail, and/or in person.

Please write in your name as the Parent/Guardian to agree to the above pledges.

Full Name

Date

FAMILY INFORMATION

Dear Parents and Guardians - In order to raise funding for the Chicago Lights Tutoring Program, we always need more information about the families we serve. Although answering these questions is optional, please help us continue to offer quality services for your child by providing the information requested below. This information will not affect your child’s acceptance to the program and will be strictly confidential. Thank you.

Neighborhood

How many years have you lived at this zip code?

Type of Housing and/or Rental Assistance:

Other:

Family Type:

Other:

How many people live in the household?

Head of household employment status:

Other:

What is the highest level of education within the household?

Other:

Who In HH Earned Highest Level Of Ed?

Monthly Household Income:

Do you have access to a computer at home?

Do you have access to the internet at home?

Do you receive SNAP (Illinois food stamps) or have a Link card?

What is your primary mode of transportation?

Other:

How did you hear about the Chicago Lights Tutoring Program?

HIDDEN PE STAGE

HIDDEN PE LeadSource

HIDDEN

Set Client (checkbox) to TRUE

HIDDEN Role

HIDDEN Student Record Type ID

Contact Information