Foster Care Council of Southwest Florida

TUTORING REFERRAL FORM FOR CHILD

Friends of Foster Children of Southwest Florida (to be completed by case manager or GAL)

Please complete the attached form in its entirety before submitting it to the Friends of Foster Children for consideration. Incomplete forms will only delay the child receiving the necessary tutoring. Please pay special attention to providing contact information for the caretaker so that we may contact him/her to arrange the tutoring. In addition, please supply all contact information necessary for the Friends of Foster Children to reach you, the case manager or GAL. As long as you submit this application with all areas completed, tutoring should be arranged quite quickly.

It is imperative that the caretaker be present with the child during the tutoring session. Tutors will not be permitted to stay with the child without the caretaker being present for the entire session.

Child’s Name
Home Phone
Caregiver’s Name
Work Phone
Address
County
Cell Phone

Can child be tutored at home? Yes No
(A parent/guardian must be present)
If no, can transportation be arranged to another setting for tutoring? Yes No

Child’s Date of Birth
Age
Grade
Child’s School
Teacher

Is child fluent with the English language? Yes No
If NO, what is primary language?
Is there a Guardian Ad Litem appointed for this child? Yes No
GAL Name

Subjects child needs tutoring in READING MATH LANGUAGE ARTS OTHER

Is child working below grade level in area subject? Yes No
Is the child ESE? YES NO Yes No

Case Manager Name
Phone
Cell
Email Address
Fax
Pager
Case Manager Agency
(ie DCF/FPS, etc.)