CORE Club Student Application Form

Student Name:

Student birthday (day/month/ year):

Age:

Grade:

Has your child previously attended CORE Club? Yes No

If yes, provide the dates of years they attended:

Parent/ Guardian names:

Parent/ Guardian occupation(s):

Email:Phone:

Preferred Contact Information:

  1. How did you hear about CORE Club?

  1. CORE Club sessions are offered Monday/Thursday from 4:30-6:00 or on Tuesdays from 4:30-6:00. Please indicate which session you prefer. (If either day is possible, please rank your preferences).

  1. Please provide as much detail as possible about the type of academic support your child requires:

  1. Has your child been assessed for any learning difficulties? YES NO
If yes, it would be helpful for us if you could share assessment results or your child’s Individualized Education Plan (IEP).Note this is not a requirement for participating in CORE Club, but may provide useful information for tutors as well as the selection committee.
  1. Is your child accessing any other educational support programs? YES NO
If yes, describe the type of support your child is receiving:
  1. Note that CORE Club tutoring is structured so that students work in small groups (2 or 3 students) with one tutor. Would your child benefit from small group instruction, or does your child need one-on-one instruction? Please providespecific reasons to support your answer.

  1. Provide as much detail as possible about the types of behavioral supports that your child requires (if applicable):

  1. What is your gross combined family income?
__ Less than $10,000
__ $10,000-$35,000
__ $35,000-$50,000
__ $50,000- $75,000
__ Above $75,000
  1. What is your total number of children/ dependents?

  1. Please provide any other details necessary to allow us to determine whether youyour family meetthe criteria for financial need.

Along with your application form, you must provide a professional recommendation for your child requiring tutoring (e.g., teacher, principal) using the provided form.

Please submit completed application to Karen E. Efford at or c/o Centre for Outreach Education, Faculty of Education

PO Box 1700 STN CSV, Victoria BC V8W 2Y2

Thank you for your help and collaboration!