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* Indicates required question
Student Name
*
Your answer
Gender
*
Female
Male
Non-binary
Prefer not to say
How if your student attenting school this Fall?
100% virtually
100% in person (after October 5th in ICSD)
Hybrid
Clear selection
Current Grade
*
Choose
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
School
*
Choose
N/A
Homeschool
South Hill
Northeast
Enfield
BJM
Fall Creek
Caroline
Belle Sherman
Cayuga Heights
DeWitt
Boynton
Ithaca High School
LACS
New Roots
Newfield
Lansing
Dryden
Trumansburg
Groton
Please mark all of the areas your student could use help in:
*
Reading
Writing
Math
Science
Languages
Executive Functioning Skills (organization and time management)
Other:
Required
Address:
*
Your answer
Parent/Guardian Name:
*
Your answer
Email:
*
Your answer
Phone number:
*
Your answer
Emergency Contact Phone Number
Your answer
Emergency Contact
Your answer
Tutoring locations/locations: (Please select all tutoring options that apply)
*
GIAC Mondays & Thursdays, 5:30pm to 7:30pm (Middle and High School Only, Limited Space)
VAI In-Person Day School Monday-Friday, 8:45am to 4:45pm (Middle and High School Only, Limited Space)
Virtual Tutoring (please indicate availability below)
Required
Will your child attend GIAC after school program?
Yes, for the 9-5:30 program
Yes, after school only
No
For virtual tutoring, what is your child's availability for tutoring (days of the week, times)?
Your answer
Do you receive Free/Reduced lunch program? (for grant purposes only)
*
Yes
No
Not sure
Does your child have an IEP or 504 plan?
IEP
504
Unsure
No
Clear selection
Ethnicity (for grant purposes only)
*
Black/African American
Latino/a (Hispanic)
Multiracial
Asian
White
Other
Required
Have you participated in this program before?
*
Yes
No
Where do you live?
*
Out of State
Town of Ithaca
City of Ithaca
Town of Dryden
Town of Lansing
Danby
Town of Ulysses
Town Caroline
Town of Newfield
Richford
Other:
Required
Is there anything you'd like us to know about your student? What do you hope your student will get from their Village academic support?
Your answer
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