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OMO Tutoring Program

Please complete this form to sign your child up for 1 hour 2x weekly tutoring with our tutoring partner The Learning Booth

Parent First Name *

Parent Last Name*

Email*

Phone Number

Student Information (Please complete a separate registration form for each student you want to register)

Name of Student registering for tutoring *

What grade is the student in?

Pre-school JK/SK 1 2 3 4 5 6 7 8 9 10 11 12 Post-secondary

Student identifies as... *

Black African Afro-Caribbean African-Canadian descent Afro-LatinX Bi- Racial

What school board does the student belong to?*Please enter dataAlgoma District School BoardAlgonquin and Lakeshore DSBAvon Maitland DSBBluewater DSBBrant Haldimand Norfolk Catholic DSBBruce-Grey Catholic DSBCDSB of Eastern OntarioCHEO SACS ViamondeCS catholique MonAvenirCS public du Grand Nord de l'OntarioCSD du Nord-Est de l'OntarioCSDC Franco-NordCSDC de l'Est ontarienCSDC des Aurores boréalesCSDC des Grandes RivièresCSDC du Centre-Est de l'OntarioCSDC du Nouvel-OntarioConseil scolaire catholique ProvidenceConsortium Centre Jules-LégerCÈP de l'Est de l'OntarioDSB NiagaraDSB Ontario North EastDufferin-Peel Catholic DSBDurham Catholic DSBDurham District School BoardGrand Erie DSBGreater Essex County DSBHalton Catholic DSBHalton DSBHamilton-Wentworth Catholic SBHamilton-Wentworth DSBHastings & Prince Edward DSBHuron Perth Catholic DSBHuron-Superior Catholic DSBJames Bay Lowlands SSBKawartha Pine Ridge DSBKeewatin-Patricia DSBKenora Catholic DSBLakehead District School BoardLambton Kent DSBLimestone DSBLondon District Catholic School BoardMoose Factory Island DSABMoosonee DSABNear North DSBNiagara Catholic DSBNipissing-Parry Sound DSBNortheastern Catholic DSBNorthwest Catholic DSBOtherOttawa Catholic DSBOttawa-Carleton DSBPeel District School BoardPenetanguishene PSSBPeterborough Victoria Northumberland and Clarington Catholic DSBRainbow DSBRainy River DSBRenfrew County Catholic DSBRenfrew County DSBSimcoe County DSBSimcoe Muskoka Catholic DSBSt Clair Catholic DSBSudbury Catholic DSBSuperior North Catholic DSBSuperior-Greenstone DSBThames Valley DSBThunder Bay Catholic DSBToronto Catholic DSBToronto District SchoolboardTrillium Lakelands DSBUpper Canada DSBUpper Grand DSBWaterloo Catholic DSBWaterloo Region DSBWellington Catholic DSBWindsor-Essex Catholic DSBYork Catholic DSBYork Region DSB

What subjects does the student require tutoring supports for? *SelectMathScienceSocial StudiesFrenchLanguage Arts High School - Math

Please list any specialized programs/supports that the student requires (i.e IEP, text to speech etc.)*

Is your child reading below grade level? (Check all that apply)*Please enter dataYes, a teacher.school has told me this Yes, my child has expressed they are having a hard time reading Yes, my own observations tell me they are reading below grade levelNo

Is your child engaged in school (example: they do their homework without being told to, they participate readily in class, they are eager to attend class each day)

Yes No Somewhat

How does your child currently feel about their academic abilities in school?*Please enter datanot at all confidentsomewhat confidentconfident

How does your child feel about going back to school in January?Please enter dataNot very excitednervous or anxiousno feelingssomewhat excitedVery excited

Do you have a laptop of computer that your child can use to access the virtual campus?*

Yes No

What technology will your child be using to access the virtual campus drop in tutoring? (Note our Omo Africentric Campus can be downloaded onto a PC or MAC. Chromebook users can access tutoring through our web-based platform)*

PC MAC Chromebook

By completing this form, I consent to having this information, including personally identifying information, shared with the tutoring company who will be providing tutoring services to the student

I agree

I understand that all tutoring sessions will be virtual. *

I agree and understand

I understand that my child must participate and attend all arranged tutoring sessions as scheduled. If my child misses more than three sessions, I understand that they will be removed from the program.*

I agree and understand

I confirm that I am not related to any Parents of Black Children employee or member of the Board. *

I agree and confirm