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):