Tutoring Application

 

ROAD TO LEARNING

Formerly Quentin Road Dyslexia Solutions

APPLICATION FOR DYSLEXIA SCREENING

and LEARNING PROGRAM

 

 

Applicant’s Name: ___________________________

Birth Date: ________________________________

Applicant’s School: __________________________

Guardian’s Name: ___________________________

Township: _________________________________

Street:_____________________________________

City:________________State:________Zip:_______

Home Phone #: _____________________________

Work Phone #: ______________________________

Mom Cell #: ________________________________

Dad Cell #:_________________________________

Mom Email: ________________________________

Dad Email: _________________________________

Authorized to Pick Up Child:___________________

Phone:_____________________________________

List Any Medications Child is Taking: ______________

____________________________________________________

List Any Testing or Diagnosing Completed (current IEP,etc.)___________________________________________

_____________________________________________________

FEE SCHEDULE

Registration…$75.00 plus 4 weeks prepaid

Tutoring Fee…$40.00/hour

Tutoring is provided by a Barton Trained Tutor.  Each tutoring session is one hour long.  We recommend at least two days a week for tutoring.  Tutoring is done in a one-on-one setting.  Tutoring can be scheduled Monday-Friday at any time between 9am and 6pm.  We have fewer tutors on Fridays, thus fewer available times

Please list your tutoring preferences:

1st Choice:     M  T  W  TH  F  (circle each 1st choice day)     Time: __________

2nd Choice:    M  T  W  TH  F  (circle each 2nd choice day)     Time:__________

3rd Choice:     M  T  W  TH  F  (circle each 3rd choice day)     Time:__________     

Your tutoring times and days will be verified in a letter that will be sent to you. 

Fees are listed above.  Charges must be prepaid for the first four weeks of actual tutoring.  Thereafter, payment will be due every week, no later than the first day of the tutoring week.  A $5.00 late fee will be charged for any payments that are more than one week behind.  Non-payment of tuition for more than two weeks may result in dismissal.  There is a $20.00 service fee for each returned check.  Road to Learning (RTL) reserves the right to refuse any future checks.

Progress in dyslexia tutoring is based on how often the student attends and how much effort they put in.  It is important to note that dyslexia can come with other conditions such as:  ADHD, depression, Tourette’s Syndrome, OCD, bipolar disorder, anxiety disorders, and other brain disorders.  Untreated, these conditions will slow the students tutoring progress and significantly interfere with his/her ability to focus and learn.  It is important to note that the above named student is struggling in one or more academic areas because he/she has many of the classic warning signs of dyslexia.  If after an initial screening, the student is not found to benefit from the RTL Program, no further payment will be required.  Upon establishing that the student requires tutoring in the RTL Program, the student may begin the program with a payment of $75.00 plus one month’s tutoring fee prepaid.

Your student sessions are standing appointments.

RTL strives to keep our program at a high level of excellence.  This requires a serious commitment from the students and the tutors.  Consistency in attendance is a primary factor in achieving educational growth.  Parents are invited to attend the tutoring sessions in an “in the background” listening mode.  Siblings of the student or other children are not to be brought to the tutoring site.  There is a $5.00 late pickup charge for each 15 minute period after the scheduled tutoring time.

Following is a list of the holidays in which R2L is closed and there is no tutoring:

New Year’s Eve       

New Year’s Day                     

Martin Luther King Day      

President’s Day                     

Spring Break; 1 week

Good Friday

Memorial Day

4th of July

Labor Day

Columbus Day

Christmas Break; 2 weeks

Thanksgiving; Wed., Thur., Fri.

We follow the Lake Zurich School District #95 calendar for the holiday dates that occur during the school year.  Summer holidays follow the National Calendar.  If a holiday is on a weekend, the day observed will be selected at RTL discretion.  On these holidays you will receive a full credit for no tutoring.  On any days when RTL is closed, or the tutor has to cancel, the full tuition amount will be credited to your account.

On days other than the holidays listed, RTL is open for business.  Any vacation or absences will be credited on your account at one half of the tuition rate if advance notice is given.  If no advance notice is given of cancellation or vacation, no tuition will be credited.  Your payment of half of the tuition holds your tutoring time, as well as covers overhead and the tutor’s salary.  Non payment of half tuition releases your tutoring time to the next name on the waiting list.  Excessive cancellations or no-shows will result in termination of services.  If you plan to discontinue services, please provide two weeks written notice for your student’s final review and exit assessment.

Please call our office at: 847-307-0073 to report any absences.

PLEASE FILL OUT THIS DUPLICATE INFORMATION:

Applicant’s Name: ___________________________

Birth Date: ________________________________

Applicant’s School: __________________________

Guardian’s Name: ___________________________

Township: _________________________________

Street:_____________________________________

City:________________State:________Zip:_______

Home Phone #: _____________________________

Work Phone #: ______________________________

Mom Cell #: ________________________________

Dad Cell #:_________________________________

Mom Email: ________________________________

Dad Email: _________________________________

Authorized to Pick Up Child:_______________________

Phone:________________________________________

Your signatures on this page creates a binding contact between the student (or the Guardian for the student) and Road to Learning, a division of Quentin Road Christian School and all Quentin Road Church Divisions.

MEDICAL RELEASE:

AUTHORIZATION:  In case of a medical emergency, I understand that my child will be transported to the hospital by the local emergency unit for treatment if the local emergency resource (police, rescue squad, etc.) deems it necessary.  My child will be transported at the expense of the parents/guardians.  It is understood that in some medical situations the staff will need to contact the local emergency resource before the parent, my child’s physician, and/or other adult acting in my behalf.  I hereby give permission to the ROAD TO LEARNING at QUENTIN ROAD CHRISTIAN SCHOOL to take whatever emergency measures (first aid, disaster, etc.) are deemed necessary for the protection and care of my child while under the supervision of the school.

 AUTHORIZATION FORM; WAIVER AND RELEASE OF ALL CLAIMS:

(Acknowledgment of risks of injury clause) “As a participant in Road to Learning, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries including death, damages or loss which I may sustain as a result of participating in any and all activities connected with or associated with such programs.”

(Waiver of claim for injury clause)  “I agree to waive and relinquish all claims I may have as a result of participating in the programs against the Quentin Road Bible Baptist Church, Christian School, Road to Learning, and Preschool and its employees.”

(Release from liability clause)  “I do hereby fully release and discharge the Quentin Road Bible Baptist Church, Christian School, Road to Learning, and Preschool, its employees and/or agents from any and all claims from injuries, including death, damages or loss which may accrue to me on account of my participation in these programs.”

(Indemnity and defense clause)  “I further agree to indemnify and hold harmless and defend the Quentin Road Bible Baptist Church, Christian School, Road to Learning and Preschool and its employees from any and all claims resulting from injuries, including death, damages and losses sustained by me and arising out of, connected with, or in any way associated with the activities of the programs.”

 This release, indemnification and hold harmless agreement is executed by the undersigned in consideration of Quentin Road Bible Baptist Church, Quentin Road Christian School, Road to Learning and Quentin Road Christian Preschool allowing my child to participate in all the program activities and other good and valuable consideration, sufficiency of which is hereby acknowledges.

 I HAVE READ AND FULLY UNDERSTAND THE ABOVE WAIVER AND RELEASE OF ALL CLAIMS AND INTEND TO BE LEGALLY BOUND BY SAME.  BOTH PARENT/GUARDIAN SIGNATURES ARE REQUIRED.

 _________________________________     _________________________________   ____________________

      Parent (Mom)/Guardian           Parent (Dad)/Guardian               date