Tutor Application

Name*

Prefix First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Date of Birth*

School Address (if applicable)

Street Address Address Line 2 City State ZIP Code

Occupation

Religious Affiliation (if any)

Section Break

1. How did you hear about the Tutoring Program?*

2. In what areas are you interested in tutoring?*

Afterschool Program
Summer Camp

3. What days/times are you available to tutor?*

4. Describe any experience you've had working with children and/or youth:*

5. What are your skills/strengths?*

6a. Have you had any criminal or legal violations (i.e. minor drug possession, fighting, petty theft, etc.)?*

yes
no

7. Do you have any psychological issues we should be aware of that could impact your work with children?*

References

Please provide us with 2 references (non-family members preferred). If possible, list references who have observed your interactions working with children or youth.

1.Name*

First Last

Phone*

Email*

Relationship to you:*

2. Name*

First Last

Phone*

Email*

Relationship to you:*