Jefferson County Public Schools

Kids ETC. East End Tutoring Centers

Student Enrollment Form

Student Name: ________________________________________________ Telephone: _________________
Parent/Guardian Name: ______________________________ Emergency Contact No.:__________________
Address: ________________________________________________________________________________
Age/D.O.B.: ________________Child will be transported by: ________________________________________
Others authorized to pick up my child are as follows:

Name: __________________________ Relationship to Child: __________________ Telephone: ____________

Name: __________________________ Relationship to Child: __________________ Telephone: ____________
My child may not be released to:________________________________________________________________

Site Location Choice: 1st Choice _______ 2nd Choice _______3rd Choice _______
1) 9th & O Baptist Church *4401 Breckenridge Ln., 40218 -- Mondays
2) Hurstbourne Baptist Church * 8800 Shelbyville Rd., 40222 -- Tuesdays
3) Zachary Taylor Elementary * 9620 Westport Rd., 40241 -- Wednesday
4) Chancey Elementary * 4301 Murphy Lane, 40241 -- Thursday
BEST TIME CHOICE: _____4 to 5 p.m. _____4:30 to 5:30 p.m. _____5 to 6 p.m.

I, the parent/guardian of ________________________________ , hereby give permission for him or her to

participate in the Kids Etc. tutoring program. In consideration of the advantages of this program, I agree to
release, indemnify, and hold harmless the Jefferson County Board of Education, the participating site, their
agents, employees, and volunteers from liability for bodily injury or property damage that might occur while on
site.

Signature: _______________________________________________________________Date: _____________

We have developed the Kids Etc. tutoring program to meet a great need in our area for tutoring. This program is being
offered for free to referred Jefferson County Public Schools (JCPS) families. Tutors are nonpaid volunteers from our
community. Therefore we ask that you respect their commitment and the efforts of Kids Etc. by adhering to the following
procedures:
If your child is unable to attend at his or her regularly scheduled time, contact the program coordinator before 3 p.m. the day
of the session so that the coordinator is able to let the tutor know in advance. Two no-shows for assigned tutor times will
result in dismissal from the program.
Your child should arrive promptly for the session. Tutors will not wait longer then five minutes from the regular start time.
You should also arrive promptly at the end of your childs session for pick-up. Two late pick-ups may result in your
dismissal from the program.
Children will be expected to come prepared to learn. Should the tutor have regular behavior problems from your child, the
program coordinator will contact you to discuss a behavior plan or possible dismissal from the program.
To help monitor your childs progress and success, there will be a monthly log that will be completed by the tutor and
student. Parents are responsible for signing the log, sharing with the childs teacher and having him or her sign, and then
returning to the program coordinator each month. Also, families will be provided with a family packet for each month with
fun activities and learning tip sheets. Some information in this packet may be required to be returned to the program site.
There will be three fun learning parent-child activities offered by Kids Etc. through the program year. The dates and
times of these programs will be announced at a later date. We ask that students participating in this program and a
parent/guardian try to attend at least one of these events.

r I have read the above information and agree to adhere to

program guidelines.

Parent/Guardian Signature __________________________________________________Date

______________________________

To be completed by the school:

School: ___________________________________________ Teacher: ___________________________________
Teachers E-Mail Address: ______________________________________________________ Grade: ___________
Family Resource Center (FRC) Coordinator: ___________________________ Telephone: _____________________
FRC Coordinators E-Mail Address: _______________________________________________
Areas of Strength: ______________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Areas of Concern: ______________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

www.jcpsky.net
Equal Opportunity/Affirmative Action Employer
Offering Equal Educational Opportunities
16326 LoweFRCenrollForm 10-11rj