After School Program Tutorial

Registration Application

Registration Application: (Submitting online)

Student Full Name *

Email address *

Preferred Name: *

Date of Birth *

Current Grade: *

School attending *

Parent/ Guardian information *

Relationship to Student *

Parent/ Guardian Phone # : *

Emergency contact Name: *

Relationship to Student: *

Emergency Contact Phone # : *

Problems or challenges to be addressed: Please describe any academic, learning, homework, orgainzation or other challenges you would like the program to address> *

Parent/Guardian Goals: *

Additional information *

I understand that the J. Smith Foundation After-School Tutorial Program provides academic tutoring, homework assistance, enrichment, mentoring, and encouragement for elementary students. I certify that the information provided on this form is accurate to *

TRANSPORTATION & PICK-UP POLICY

Greater Union Baptist Church will provide transportation for participating students from Morningside Elementary to Greater
Union Baptist Church on tutorial days (Tuesday and Thursday). Parents or guardians are required to pick up their child
from the church no later than 6:15 p.m. on each tutorial day. This is a strict policy that will be enforced. If the 6:15 p.m. pick-
up policy is not adhered to, the student may lose the right to participate in the J. Smith Foundation After-School Tutorial
Program.

Parent/Guardian Acknowledgment *

Yes, I understand