Confidential: Please Print Or Type and Return As Soon As Possible To

CONFIDENTIAL: PLEASE PRINT OR TYPE AND RETURN AS SOON AS POSSIBLE TO:

DYSLEXIA TUTORING PROGRAM, INC. (formerly MADAY)

THE ROTUNDA/ SUITE 310 / 711 WEST 40TH STREET

BALTIMORE, MARYLAND 21211

NAME:
ADDRESS:
CITY: / STATE: / ZIP CODE:
HOME PHONE: / WORK PHONE:
CELL #: / EMAIL ADDRESS:
EMPLOYER/SCHOOL:
ADDRESS:
CITY: / STATE: / ZIP CODE:
OCCUPATION: / HOW LONG? YRS.
SEND MAIL TO: HOME BUSINESS / BIRTHDATE:
HOW DID YOU HEAR ABOUT THE DYSLEXIA TUTORING PROGRAM?
WHY DO YOU WANT TO BECOME A VOLUNTEER FOR OUR PROGRAM?
WHAT APPEALS TO YOU ABOUT THIS PARTICULAR VOLUNTEER SERVICE?
WHAT IS YOUR HIGHEST GRADE COMPLETED IN SCHOOL?
SCHOOL / YEAR GRADUATED / DEGREE
LIST ANY EMPLOYMENT OR VOLUNTEER EXPERIENCES WHICH YOU BELIEVE CONTRIBUTED
TO YOUR PREPARATION FOR THIS VOLUNTEER ASSIGNMENT:
ORGANIZATION / YRS. INVOLVED / CONTACT PERSON / PHONE NUMBER
HAVE YOU EVER BEEN TERMINATED FROM A JOB?YESNO
IF YES, PLEASE EXPLAIN CAUSE FOR DISMISSAL:

OVER >

HAVE YOU EVER BEEN CONVICTED OF A FELONY OR A MISDEMEANOR?
YESNO
IF YES, EXPLAIN:
WOULD YOU SUBMIT TO A BACKGROUND CHECK IF NECESSARY?
YES NO
DO YOU KNOW OF ANYTHING WHICH WOULD PREVENT YOU FROM MEETING WITH A CLIENT
ON A CONSISTENT BASIS UNTIL COMPLETION OF AT LEAST 60 HOURS OF INSTRUCTION?
YES NOIF YES, PLEASE EXPLAIN:
THE DYSLEXIA TUTORING PROGRAM IS AN ALCOHOL AND DRUG FREE PROGRAM.
REFERENCES: PLEASE LIST THE NAMES, ADDRESSES AND PHONE NUMBERS OF THREE (3)
PERSONS WHOM WE MAY CONTACT WHO HAVE KNOWN YOU FOR AT LEAST TWO YEARS. ONE REFERENCE MAY BE AN EMPLOYER. PLEASE WRITE LEGIBLY AND GIVE COMPLETE
ADDRESSES WITH ZIP CODES. PLEASE DO NOT USE RELATIVES!
1. NAME: RELATIONSHIP
ADDRESS:
CITY: STATE:ZIP CODE:
PHONE:
2. NAME: RELATIONSHIP
ADDRESS:
CITY:STATE:ZIP CODE:
PHONE:
3. NAME: RELATIONSHIP
ADDRESS:
CITY:STATE:ZIP CODE:
PHONE

I CERTIFY THAT THE INFORMATION GIVEN BY ME IN THIS APPLICATION IS TRUE IN ALL RESPECTS, AND I AGREE THAT IF I AM ACCEPTED AS A VOLUNTEER AND IT IS FOUND TO BE FALSE IN ANY WAY, THAT I MAY BE SUBJECT TO TERMINATION FROM THE DYSLEXIA TUTORING PROGRAM. I UNDERSTAND THAT COMPLETION OF THIS APPLICATION IS NOT A GUARANTEE OF ACCEPTANCE INTO THE DYSLEXIA TUTORING PROGRAM. I FURTHER UNDERSTAND THAT IF I AM TAKING THE CLASS FOR PERSONAL OR PROFESSIONAL REASONS OR FAIL TO FULFILL MY COMMITMENT TO TUTOR A CLIENT ACCEPTED BY THE DYSLEXIA TUTORING PROGRAM, THAT I WILL BE RESPONSIBLE FOR REIMBURSING THE DYSLEXIA TUTORING PROGRAM THE $500 COST OF MATERIALS AND TRAINING.

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