Tutor Connection - Tutoring Referral Form 
Foster Youth Services Coordinating Program & Homeless Education Services

Please note that tutoring services require a MINIMUM commitment of 2 HOURS PER WEEK during the school year AND adult supervision during tutoring times.  Also note tutoring starts in September for fall semester and January for spring semester.

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Referrer - Name *
Referrer - Phone Number: *
Referrer - Email: *
Student Information
Student - First Name: *
Student - Last Name: *
Gender: *
Grade: *
Age: *
Date of Birth: *
MM
/
DD
/
YYYY
What days and times are best for tutoring *
School Attending: *
School District: *
Does the student receive any special education services? *
Student status: *
Required
Tutoring Subjects Requested: *
Required
Tutoring Services Requested: *
Please let us know if IN PERSON or VIRTUAL tutoring would work best for the student. If VIRTUAL is selected, please make sure student will have an available device to receive tutoring services virtually. If no preference, select both options for a greater chance of being matched with a tutor.
Required
Caregiver Contact Information
Please identify the individual who the tutor will contact to make arrangements for tutoring sessions.
Caregiver - Full Name: *
Relationship: *
Caregiver - Address: *
Please make sure to write out the caregiver's complete address.
City *
Caregiver - Phone Number: *
Caregiver - Email:
If the caregiver is a non English speaker, please specify language:
Child Welfare Services Information
Placement Type: *
What region is the CWS Social Worker assigned to?
Clear selection
CWS Social Worker - Name:
CWS Social Worker - Phone Number:
CWS Social Worker - Email:
Any additional information or accommodations requested (ie. tutor gender preference, ethnicity, tutoring language preference):
Caregiver and youth are required to participate   2-3 hours every week for the entire semester.  Caregivers will call tutor 24 hours in advance to cancel tutoring session. If tutoring is canceled more then 3 times you may not be eligible for tutoring. An adult will always be present during tutoring. *
Thank you!
After submitting this form you will be emailed a copy of your submission. We will do our best to match your student with a tutor.

If you have any questions, please contact Michelle Bailow at: mbailow@sdcoe.net or 619-293-3496.

Thank you!
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