Student Information
Student Contact Information
First Name* 
Last Name* 
Mobile Phone  
Email Address 
Date Of Birth* 
Home Address* 
Nationality* 
First Language * 
State* 
City* 
Zip* 
Gender* 
Parent Information
Parent Contact Information
First Name*
Last Name*
Mobile Phone*
Email Address* 
Relationship 
Home Address 
Nationality  
First Language * 
Second Parent Information
Parent Contact Information
First Name 
Last Name 
Mobile Phone
Email Address  
Relationship 
Home Address 
Nationality  
First Language  
STUDENT ACADEMIC INFORMATION
Grade of Student (Last Grade Completed)* 
Curriculum
Additional Notes 
Has student ever received Special Education Needs Services? 

If yes, please provide details and upload IEP or SEN documents
I am an ESL Student. (English is not my first language)
Documents
"For K-9 please attach a copy of the student's passport and the most recent yearly report card"
"For 10-12 please attach a copy of the student's passport and all high school report cards."
LEARNING COACH
Name of Designated Learning Coach * 
 * Please check if the designated learning coach has read and understand the Learning Coach Responsibilities

LEARNING COACH RESPONSIBILITIES

I understand that the Learning Coach (LC) is the adult in the home who will assist the student with completing their daily tasks. The amount of assistance depends on the student's grade level and the student's ability to complete work independently.

Elementary School (K-5)

A lot of monitoring is required for students in Grades K-5. The Elementary School Learning Coach will be actively involved with the student spending an average of 3-6 hours each day. During a typical week, the Learning Coach will:

·         Assist with lessons

·         Monitor comprehension

·         Modify daily schedule

·         Log attendance

·         Communicate with teacher

Middle School (6-8)

The type of assistance provided by the Middle School Learning Coach varies, based on the student's independence. The Learning Coach will spend an average of 2-4 hours a day. During a typical week, the Learning Coach will:

·         Assist with some lessons

·         Monitor comprehension

·         Encourage independent learning

·         Log attendance

·         Communicate with teachers

High School (9-12)

The High School Learning Coach may spend less time assisting their student based on the student's ability to work independently. The average amount of time spent by the Learning Coach with a High School student is 1-2 hours a day. During a typical week, the Learning Coach will:

·         Assist with some lessons, varies based on student's independence

·         Verifies lesson completion to ensure student is on track

·         Supports student independence

·         Attends teacher conferences