45 Bristol Street, New Haven, CT 06511 information@newhavenreads.org 203-752-1923

Waitlist Application 2

    Student Information
    Date (required):
    Student’s Name (required):
    Address (required):
    City (required):
    Zip Code (required):
    Date of Birth (required):
    Age (required):
    Gender (required):
    School (required):
    Current Grade (required):
    Does he/she have any siblings enrolled in the NHR tutoring program? (required)
    If yes, please list:
    Preferred Day for Tutoring:
    Preferred Time:
    Has he/she ever been retained? (required)
    If yes, what grade?
    Have you received notification that he/she will be retained? (required)
    Does he/she receive special services at school? (required)
    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?
    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):