READERS ARE LEADERS returning VOLUNTEER TUTOR APPLICATION Training sessions are not required, however, if you would like a refresher, training sessions will be available in August, September and October and will be posted on our calendar after July 19, 2019. Complete the entire Tutor application, the KUSD Background Check Form is not required. If you have any questions, please contact us at email@example.com or call 262-658-4104. Thank you. Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Name * Email * Has your phone number, address, or emergency contact information changed from last school year? * Yes No Phone Number Address City State Zip Code Emergency Contact Emergency Contact Telephone Number of years you have tutored * Which school did you tutor at for the 2018/19 school year? * Brass Forest Park McKinley Wilson Would you like to return to the same school you tutored at for the 2018/19 school year? * Yes No If you would not like to return to the same school, please select a school you would prefer to tutor at Brass Forest Park McKinley Wilson If you are returning to the same school and the student you tutored is in the program, would you like to continue to tutor them? Yes No If yes, please list the students name Please select the grade level you are comfortable working with (check all that apply) 1st Grade 2nd Grade 3rd Grade No Preference ALL NON-FOREST PARK TUTORS - Please check the day(s) you would prefer to tutor (check all that apply) Please note if you are staying with the student you tutored in the 2018/19 school year, you may be scheduled for a different day or time based on their availability Monday Tuesday Wednesday Thursday No preference ALL NON-FOREST PARK TUTORS - Please check the time of day you would prefer to tutor (check all that apply) Early Morning (8am - 10am) Late Morning (10am - 12pm) Early Afternoon (12pm - 2pm) BRASS TUTORS ONLY Late Afternoon (2pm - 4pm) No Preference FOREST PARK TUTORS ONLY, please check the day(s) you would prefer to tutor Mondays (between 8:40am-10:40am) Tuesdays (between 9:15am-11:00am) Wednesdays (between 8:40am-10:40am) Thursdays (between 9:15am-11:00am) No Preference Are you interested in tutoring more than one student? * Yes No Do you have any special needs we should consider for your tutoring placement? If you have special needs, such as difficulty with stairs, please list here. If you have no special needs, list N/A Consent to Share Confidential Information * I understand that the volunteer screening process includes a criminal background check. I give permission to have the results of this check shared with placement sites as it pertains to my involvement as a volunteer. In checking this box, I agree to the above statement Confidentiality Agreement * I understand that in providing my services as a volunteer with Readers Are Leaders Tutoring Program, I will respect the confidential nature of the knowledge I will gain concerning the academic performance, behavior, and personal information of the children with whom I work. If a child tells me something or I notice something that may indicate his/her safety is at risk or he/she is in emotional distress, I will report that information to my supervising teacher, site coordinator, school principal or office staff. In checking this box, I agree to the above statement Contact with Children/Families * I will not initiate contact with the children with whom I work or their families outside of the school or program setting to which I have been assigned. In checking this box, I agree to the above statement. Release of Likeness * United Way of Kenosha County may take photographs or videos of participants, individually or in groups, attending or taking part in United Way programs and activities. These images, in original or modified form, may appear in future United Way publications and/or publicity, including print, web and video productions. Anyone who attends or participates in a United-Way-hosted event or activity authorizes the use and reproduction of any photographs taken during the event, without compensation by United Way. The opportunity or right to inspect or approve any such images or recordings is waived. If an individual does not wish to be photographed or videotaped, the person must notify the United Way staff to that effect. Permission for usage is assumed for any photographs submitted to United Way by an individual or organization. All images and files shall constitute United Way property, solely and completely. In checking this box, I agree to the above statement. In checking this box, I do not agree with the above statement Criminal Background Check * I understand that the criminal background check submitted to United Way of Kenosha County is in accordance with the Kenosha Unified School District Policy 4332. The background check will be submitted, processed, and approved or denied by Kenosha Unified School District who will inform United Way of Kenosha County of the decision. To review the policy, please visit http://www.kusd.edu/4332-criminal-background-checks. In checking this box, I agree to the above statement I certify that the information stated in this volunteer tutor application is true to the best of my knowledge * Yes No Date of verification * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.