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Blue Ribbon Educators Parent Intake Form
Please provide your information so we can match you and your student(s) with the best educator. We will be in touch shortly!
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* Indicates required question
Email
*
Your email
Contact Parent Last Name
*
Your answer
Contact Parent First Name
*
Your answer
Contact Parent Phone Number
*
Your answer
School Name and District
*
Your answer
I am looking for face to face instructional support in my home.
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Yes
No
I am looking for on-line instruction.
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Yes
No
My first choice of Educator is (choose one) :
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Teacher After School - credentialed, highly qualified and Blue Ribbon Educator certified
Special Education Teacher After School - credentialed, highly qualified and Blue Ribbon Educator certifified
Education Assistant After School - trained, highly qualified and Blue Ribbon Educator certified Teacher's Assistant
In person Zoom Assistant During School hours -- trained Blue Ribbon Educator certified assistant to support students during the school day while they attend virtual Zoom classes and complete assignments.
My second choice of Educator is (choose one) :
Teacher After School - credentialed, highly qualified and Blue Ribbon Educator certified
Special Education Teacher After School - credentialed, highly qualified and Blue Ribbon Educator certifified
Education Assistant After School - trained, highly qualified and Blue Ribbon Educator certified Teacher's Assistant
In person Zoom Assistant During School hours- trained Blue Ribbon Educator certified assistant to support students during the school day while they attend virtual Zoom classes and complete assignments.
Clear selection
Type of support?
*
We have a Fully-Formed pod
We have part of a pod - looking for more students
I only want tutoring for my child
Which neighborhood is home or pod located in? (West LA includes - Westwood, Palms, Bel Air, Beverly Hills, Culver City, Mar Vista, Santa Monica, Venice, Playa Vista etc.) (check all that apply)
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West LA
Valley
Mid City
Palisades
Other:
Required
Student 1: Student First and Last Name
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Your answer
Student 1: Student Grade for 20-21
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Your answer
Student 1: Parent Legal Name
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Your answer
Student 1: Parent Email
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Your answer
Student 1: Parent Cell Phone
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Your answer
Student 1: Parent Address
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Your answer
Student 2: Student First and Last Name
Your answer
Student 2: Student Grade for 20-21
Your answer
Student 2: Parent Legal Name
Your answer
Student 2: Parent Email
Your answer
Student 2: Parent Cell Number
Your answer
Student 2: Parent Address
Your answer
Student 3: Student First and Last Name
Your answer
Student 3: Student Grade for 20-21
Your answer
Student 3: Parent Legal Name
Your answer
Student 3: Parent Email
Your answer
Student 3: Parent Cell Number
Your answer
Student 3: Parent Address
Your answer
Student 4: Student First and Last Name
Your answer
Student 4: Student Grade for 20-21
Your answer
Student 4: Parent Legal Name
Your answer
Student 4: Parent Email
Your answer
Student 4: Parent Cell Number
Your answer
Student 4: Parent Address
Your answer
Student 5: Student First ad Last Name
Your answer
Student 5: Student Grade for 20-21
Your answer
Student 5: Parent Legal Name
Your answer
Student 5: Parent Email
Your answer
Student 5: Parent Cell Number
Your answer
Student 5: Parent Address
Your answer
Student 6: Student First and Last Name
Your answer
Student 6: Student Grade for 20-21
Your answer
Student 6: Parent Legal Name
Your answer
Student 6: Parent Email
Your answer
Student 6: Parent Cell Number
Your answer
Student 6: Parent Address
Your answer
Preferred Instructional Hours (check all that apply)
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During the School Day Hours
After School Hours
Evenings
How many hours per week of instruction are you looking for?
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4 hours a week after school
6 hours a week after school
20 - 25 hours a week during the school day
How did you hear about Blue Ribbon Educators?
*
Choose
Word of Mouth
Website
Child's Teacher
Other
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