Boys & Girls Club of Anytown

Boys & Girls Club of Anytown Name of Unit/Branch

APPLICATION for Participation FY16

Date: ______

First Name: ______Middle: ______Last: ______

Gender: ___M ___F Ethnicity: ______DOB: ______SSN: ______

Physical Mailing Address: ______

City: ______Zip: ______

Phone: ______Parent Email: ______

Emergency Contact: ______Emergency Phone: ______

School Information: School: ______Grade: ______

I understand that my child will be assessed academically by Sylvan Learning Center while at the Boys & Girls Club. He/she may be selected to receive FREE tutoring and remediation services. I consent to these services and will support my child throughout the program.

Parent Signature: ______

Member’s Signature: ______Please complete Eligibility Questions and Academic Background Questions. Club Staff Use Only: AIM Service: Ace it Camp Subject: Reading Math Coding Engineering Fit4Algebra Writing Date Service Started: ______Date Service Completed: ______If not complete, when was last day of service? ______Boys & Girls Club of Anytown Name of Unit/Branch TEXAS AIM ELIGIBILITY QUESTIONS Club Member Name: ______

Please select at least one criteria appropriate and all that apply:

□ Single Parent home □ English is NOT the primary language spoken in the home □ exhibits delinquent conduct (Texas Family Code §51.03) □ eligible for a free or reduced lunch (Texas Education Code §33.151) □ in family conflict or crisis (Texas Education Code §33.151) □ is a Temporary Assistance for Needy Families (TANF) recipient □ is a student of Limited English Proficiency as defined by Section 29.052; □ is homeless as defined by 42 U.S.C. Section 11302 and its subsequent amendments; or □ was not advanced from one grade level to the next for one or more school years; □ if the student is in grade 7, 8, 9, 10, 11 or 12, did not maintain an average equivalent to 70 on a scale of 100 in two or more subjects in the foundation curriculum (Section 28.002) during a semester in the preceding or current school year, or is not maintaining such an average in two or more subjects in the foundation curriculum in the current semester; □ did not perform satisfactorily on an assessment instrument administered to the student under Subchapter B, Chapter 39, and who has not in the previous or current school year subsequently performed on that instrument at a level equal to at least 110 percent of the level of satisfactory performance on that instrument; □ is a student in pre-kindergarten, kindergarten, or grade one, two or three who did not perform satisfactorily on a readiness test or assessment instrument administered during the current school year; □ is pregnant or is a parent; □ has been placed in an alternative education program in accordance with Section 37.006 during the preceding or current school year; □ has been expelled in accordance with Section 37.007 during the preceding or current school year; □ was previously reported through the Public Education Information Management System (PEIMS) to have dropped out of school; □ is in the custody or care of the Department of Protective and Regulatory Services or has, during the current school year, been referred to the department by a school official, officer of the juvenile court or law enforcement official; □ resided in the preceding school year or resides in the current school year in a residential placement facility in the district, including a detention facility, substance abuse treatment facility, emergency shelter, psychiatric hospital, halfway house, or foster group home. □ Student who satisfies local eligibility criteria adopted by the board of trustees of a school district by section TEC 29.081(g). Boys & Girls Club of Anytown Name of Unit/Branch ACADEMIC BACKGROUND QUESTIONS

Club Member Name: ______Student School/Grade: ______

In order to determine what academic support is most appropriate for your child we ask you to answer the following questions with as much detail as possible. As a Boys & Girls Club Member, your child may qualify for FREE services through Sylvan Learning and Ace It Tutoring.

1. What were your child’s most current report card grades in the following subjects?

a. Math ______

b. Reading ______

c. Writing ______

2. What were your child’s grades a year ago in the following subjects?

a. Math ______

b. Reading ______

c. Writing ______

3. Is your child currently receiving any supplemental support in school (tutoring, resource, pull out from regular class, small group instruction, etc)?

4. If applicable, how did your child perform on the STAAR test in the past (please give history - all subjects all grades)?

5. Has your child been tested or diagnosed with a learning disability? Boys & Girls Club of Anytown Name of Unit/Branch

6. If so, what accommodations is he/she receiving, and have you seen progress as a result of these accommodations?

7. Has your child ever been retained? If so, please explain grade and circumstances.

8. Would you like to share any other information relevant to your child’s past academic performance?