Higher Heights Tutoring Intake Form 2021 - 2022
Welcome to your Tutoring Program offered through Higher Heights Youth Empowerment Programs, Inc.

Our tutoring program gives children extra opportunities to improve their Math, English/Reading, Science, and Social Studies skills.

Your child will meet individually with a tutor. These tutoring sessions will take place once per week (per subject as needed). Each session will last about 60 minutes.

Tutoring sessions will be scheduled so that your child does not miss important classwork.The goal of these tutoring sessions is to help your child to become a more skilled and confident student.


Please complete the attached form so we can better prepare your individualized tutoring program for you.
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Student First Name *
Student Last Name *
Student's Email address
Parent's Full Name *
Parent's Email Address *
Parent's Phone Number *
Ethnicity (Student) *
Student's Date of Birth *
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Student's Street Address & Zip Code *
Does the Student live in a Dual-Parent Household? *
Does the Student live in a Household with a Female Head-Of-Household? *
Please select your income level.  This information will not determine your enrollment into the program. It is tracked for funding purposes. *
Are you a case manager referring a student?
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If so, please list your first and last name and email address.
If you are utilizing this service through UCA and you have been assigned a case manager, please list their full name below
Student's grade level *
Please select the days you are interested in receiving tutoring.  Each session is 60 minutes. *
Required
Please share the subject your child needs assistance in (If the subject is Math, please include the area they will need assistance in - for example: Algebra, Geometry, etc) *
Name of your child's current school *
How did you hear about Higher Heights? *
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