Mathematics Clinic Interest Form 
This is an interest form for anyone interested in their child participating in the Mathematics Clinic offered at Appalachian State University. This Mathematics Clinic will be focused on supporting students who are 1st through 4th grade. Please answer each question below and list any other additional questions at the end. Thank you so much for your interest in the Mathematics Clinic! 
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Please List Your Name  *
List Student Name *
Why are you interested in your child participating in the Mathematics Clinic?  List any areas of concern related to math.  (Please note, at this time, the clinic is for students that struggle with mathematics; it is not an enrichment program.)  *
How old is your child? *
What grade is your child in? *
What school do they currently attend? *
Are they receiving special education services? *
What type of classroom are they currently in?  *
Which Mathematics Clinic campus are you interested in? *
Would you be able to provide transportation to Appalachian State Campus (Boone/Hickory) for your child two days a week for the Mathematics Clinic? 
(drop off at 3:50pm / pick up at 5pm) 
 *
Regular attendance is a requirement of participation in the Mathematics Clinic.  Multiple absences my cause your child to loose their place in the clinic.  Will your child be able to attend on a consistent basis? *
What questions do you have for us?  *
Please provide your contact information (email and phone number)  *
What is the best way to contact you? (Check all that apply.) *
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