Virtual Study Buddy Registration

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Fall 2020

Student Name *

Grade *

Guardian Name *

Guardian Email *

Guardian Phone *

Preferred contact method: *

Phone (call)

Phone (text)

Required

What characteristics do you think are important for your student's buddy to possess in order to be a positive match? Any characteristics that would be challenging for your student? *

What do you hope your student will gain from participating in the virtual study buddy & mentor program? This can be an academic skill, social skill or other goal you would like to see your student work towards. *

If your student has special needs or an IEP, we'd like to communicate with you and the school. Please let us know what you are comfortable sharing: *

My student has an IEP or special needs; I CONSENT to information sharing.

My student has an IEP or special needs; I DO NOT consent to information sharing.

My student does not have an IEP or special needs.

*PLEASE NOTE: In order to allow all students the opportunity to participate, the highest price indicated covers the cost of one student; it is only a recommended cost. We ask you pay what you are able. There is no income verification or scholarship application. We trust that you know what works for your household. Please let us know what you are able to contribute and we will send you an invoice for that amount. We will also apply remaining funds from the canceled Spring session. *

The next three questions are solely for collecting information for grant reporting and do not affect student enrollment. *

My student qualifies for the free & reduced lunch program.

My student does not qualify for the free and reduced lunch program.

I'd rather not answer this question.

What is your student's gender identity? Please use the OTHER line to share your response or you can choose not to answer. *

Prefer not to answer

Other:

How does your student identify racially? Please use the OTHER line to share your response or you can opt not to answer.

Prefer not to answer

Other:

Clear selection

Anything else you'd like to share about your student?

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