Student Intake Form
Learning Bridge matches community volunteers with kids in foster care to give them the educational support they need to stay in school, improve academic performance, and achieve greater success later in life. The match and tutoring will be tailored to the needs and goals of each student. There is no cost for the tutoring, but foster families/guardians must commit to ensuring that the student shows up to tutoring sessions weekly, and filling out periodic progress reports. Ongoing support will be provided by Learning Bridge.

This application should be filled out by the caregiver of the student being referred, the student themselves if they can complete it independently, OR the caseworker with the caregiver's permission if interested in the program.

Sign in to Google to save your progress. Learn more
Email *
Name of Student *
Is Student currently in foster care, a kinship placement or Family Based Safety Services? *
Required
Does Student have an open CPS case? *
Name of Foster Parent/Guardian *
Address
What county does the student reside in? *
Street *
City *
Zip Code *
Caregiver Phone (###-###-####) *
Caregiver Email (If person filling out this form is not the caregiver) *
CPS Worker Information
Name of CPS Worker *
Email address of CPS Worker *
Phone # of CPS Worker *
Student information (may be completed by Student if 14 or older):
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Ethnicity
Is the student of Hispanic origin?
Clear selection
Gender
Clear selection
Pronouns
Clear selection
Primary Language *
School District *
School attending *
The student needs help with *
Required
What other supports does the Student have (mentor, etc.?)
Has the Student expressed interest in having a tutor? *
Does the Student have any special needs?
Is the Student in special education or does he/she/they have a 504 plan?
What is the Student’s learning style?
What is the Student’s greatest strength? *
What is the Student’s greatest challenge? *
What goals does the Student have? *
What qualities/experience would be important for this student to have in a volunteer tutor? *
Does the Student have any hobbies or interests?
Do you have a preference to work with a male or female tutor? *
Program Requirements
Do you, or the student, prefer tutoring virtually, via Zoom, or in person? *
Do you have the technology to enable the Student to work with a tutor virtually once a week? *
If in-person, can you commit to being in the home while these sessions take place? *
Can you commit to reaching out to Learning Bridge if you have any concerns about your tutor or the program? *
Can you commit to completing periodic forms about the Student’s progress and maintaining regular communication with the tutor and Learning Bridge? *
Please check here if you wish to opt out of Learning Bridge Newsletter.
 Compliance with Policies and Procedures
As a participant in Learning Bridge, you and your Student agree to abide by the policies and procedures of the organization.    
https://learningbridgetx.org/LearningBridgeExpectationsGuidelinesAndPolicies.pdf
Tutor Acknowledgement
You understand and agree that Learning Bridge tutors are volunteers and are not Learning Bridge employees.  Neither the tutor, the tutoring sessions, nor the content of any tutoring session will be supervised by Learning Bridge. You understand that you are solely responsible for supervision of the tutor during any tutoring session with the Student.  Each volunteer tutor has consented to and passed a background check performed by a third party; you understand and agree that Learning Bridge makes no warranty about the completeness, reliability, or accuracy of the criminal background screening.
COVID Acknowledgment
You acknowledge the contagious nature of the Novel Coronavirus, COVID-19, and the variants of this virus (collectively “COVID-19”).  The CDC acknowledges that there is still much that remains unknown about COVID-19..  Accordingly, at your discretion, you may invite your Learning Bridge tutor to meet with your Student for in-person tutoring.  By engaging in in-person tutoring, you agree to stay up to date and compliant with CDC recommendations, including not engaging in any in-person activities for Learning Bridge if you, your Student, or anyone in your household is feeling sick.  

You further acknowledge that Learning Bridge has put in place preventative measures to reduce the spread of the COVID-19. You further acknowledge that Learning Bridge cannot guarantee that you, your Student, or others in your household will not become infected with the COVID-19.  
Release of Liability
You agree to accept and assume all of the risks which accompany the tutoring sessions and represent that your participation and your Student’s participation in the tutoring sessions are purely voluntary.  On behalf of yourself and your Student, you agree to release from liability and not to sue Learning Bridge or its volunteers, directors, board members, officers, employees, or agents for any present or future claims that may arise from or relate to the tutoring services provided by Learning Bridge and its volunteers, including claims based on negligence.
By signing below, you confirm that you understand that by signing this document, you are giving up legal rights and remedies on behalf of yourself and your Student.
Signature *
Print Name *
Student Name: *
Relationship to Student *
Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Learning Bridge. Report Abuse
Google Forms