STAR - Online Application for the School Year 2010-11 program

Tutor's Personal Information

Last Name:

First Name:

Social Security Number:

Check here if you don't have your SSN now. Please include it on your Parent Permission form.

Birthday:

Home Address:

Address:
Apt #:
City:
State:
Zip:
Home Phone:
Cell Phone:
Your Email Address:

Parent/Guardian:

Name:
Relationship:
Home Phone:
Work Phone:
or Cell Phone:
Email Address:

In Case of Emergency please contact (if the parent/guardian above cannot be reached):

Name:
Relationship:
Home Phone:
or Work Phone:
or Cell Phone:
Email Address:

School Information

The School You Currently Attend:
If your school is not listed, please enter its name and borough here:
List the name of a teacher, guidance counselor, or principal from your school:
What grade are you in?
Does your school have a community service requirement?	Yes No
If so, please indicate the number of hours you must complete:
If you plan on going to college, where would you like to attend?:
What would you like to study in college?:

Experience

Do you work for any of the following? (Other)

If you have been a READ tutor before, please list where and when you volunteered or worked for READ:

Site Name:	Summer or After School? Summer After School	Year:
Site Name:	Summer or After School? Summer After School	Year:
Site Name:	Summer or After School? Summer After School	Year:

What days are you available to volunteer after school? (Check ALL that apply)

Monday Tuesday Wednesday Thursday Friday

What time are you dismissed from your school on the days you are available?

Monday: Tuesday: Wednesday: Thursday: Friday:

If 18 years of age or older, have you ever been convicted of a crime? Yes No If you answered 'yes', please explain:

Please call the tutor information line at (646) 867-6111 with any questions.

By checking this box I agree to the following:

I certify that I will attend a scheduled READ tutor training, actively participate in the READ program by tutoring two days per week, be a good role model, and do my best to fulfill my READ tutoring commitment. I will check my email regularly to receive announcements regarding tutor parties and events, program cancellations, and any additional information. I will also fax, send or hand deliver my parent permission form to the READ office or bring it to my scheduled tutor training.

When you click the 'apply' button, below, you will see a page that you must print. It will contain the instructions that will allow you to complete your application.

READ Tutor Application Form: School Year 2010-11

Tutor's Personal Information

School Information

Experience