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Waitlist Application 2
Student Information
Date (required):
Student’s Name (required):
Address (required):
Apartment:
City (required):
Zip Code (required):
Date of Birth (required):
Age (required):
Gender (required):
M
F
School (required):
Current Grade (required):
Does he/she have any siblings enrolled in the NHR tutoring program? (required)
Yes
No
If yes, please list:
Preferred Day for Tutoring:
Preferred Time:
Has he/she ever been retained? (required)
Yes
No
If yes, what grade?
Have you received notification that he/she will be retained? (required)
Yes
No
Does he/she receive special services at school? (required)
Yes
No
If yes, describe:
Please include any additional information that may affect his/her academic progress:
Do you have a computer at home with internet connection?
Yes
No
What is the primary language spoken at home? (required)
Guardian Contact Information
Primary person student lives with (required):
Relationship to student (required):
Home Phone:
Cell Phone (required):
Email Address (required):
Parent/Guardian Signature (required):
Date (required):
Waitlist Application 2