Reading Center - Summer 2026 Tutoring Application

*Your Child's First Name:
*Your Child's Last Name:
*Birth Date:
 
*Current Grade
*Primary Language(s):
*Gender:
     Male
     Female

1. 
   *Has your child attended the Reading Center before?
       Yes
       No
   

*First Name:
*Last Name:
*Relationship to Child:
*Address:
*City:
*Zip Code:
 
*Primary Email:
*Primary Phone:
Secondary Phone:
*Primary Language(s):

First Name:
Last Name:
Relationship to Child:
Address:
City:
Zip Code:
 
Primary Email:
Primary Phone:
Secondary Phone:
Primary Language(s):

Please complete all questions. If you are unsure about any of the information requested, please consult your child's teacher.

1. *School:
2. *Classroom/Homeroom Teacher:
3. School Phone:
4. Teacher's E-mail (if known):
5. Other school personnel working with my child:
6. 
   *If we need further information about your child, may we contact your child's teacher?
        Yes
        No
   
   
   

7. Scholarships are limited! To be considered for a reduced tuition financial need has to be verified by BOTH your signature and your child's school using this form or the equivalent documentation.

   To be eligible for a financial-based scholarship you must answer the following question:

   Does your child qualify for free or reduced lunch?
        Yes
        No
   
   
   
8. *Does your child have an Individual Education Program (IEP)? If yes, you will be asked to bring a copy when your child comes in for screening.
        Yes
        No
        Decline to Answer
   
   
9. *Has your child received an Individualized Reading Improvement Plan (IRIP)? (K-3 only)
        Yes
        No
        Not Sure
   
   Does your child receive any special services at school?
        Yes
        No
   
   What do they receive?
   
10. *Describe information you've received from your child's school that demonstrates their reading difficulties. (e.g., grades, written comments from teacher, test scores)
    
    
11. Has your child ever attended other reading programs? If so, please list. (Sylvan, Reading Rx, etc.)
    
    

1. *What are your specific concerns about your child's reading and writing?
   

2. Please rate your agreement with the following statements.

   *My child is motivated to read.
        Strongly Agree
        Agree
        Neutral
        Disagree
        Strongly Disagree
   
   *My child can stay focused on a reading task.
        Strongly Agree
        Agree
        Neutral
        Disagree
        Strongly Disagree
   
   *Behavior management is a struggle for my child during reading.
        Strongly Agree
        Agree
        Neutral
        Disagree
        Strongly Disagree
   
   *My child enjoys reading.
        Strongly Agree
        Agree
        Neutral
        Disagree
        Strongly Disagree
   
   *My child lacks confidence around reading.
        Strongly Agree
        Agree
        Neutral
        Disagree
        Strongly Disagree
   
   
3. Do you want to add anything else about your child's attitude toward reading?
   

1. Tutoring schedule is from: Wednesday June 10 through Wednesday, July 8.
   
2. 
   *Finally, how did you hear about the Schmoker Reading Center? (check all that apply)
        Our facebook page
        Referred by child's teacher/school
        Our website
        Your School newsletter/website
        Reading center postcard
        Referred from friend/relative
        Magazine Ad
        Other (please specify):
       Other: