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Parent/Guardian Information

If you need assistance in completing this registration, please email info@avenue941.com. **RUBONIA COMMUNITY CENTER IS COMPLETELY FULL. Please register for a different location. Thank you.**
Parent/Guardian Name*
Parent/Guardian Address*

Student Information

Student Name Actions
In addition to tutoring, we have a partnership with Samaritan Counseling. Would you be interested in free private counseling for your student and/or your family?*
Please check if you also need support with the following resources so that we may refer you to other organizations who support our families through the Unite Us platform.*
I understand that by completing this questionnaire, my students will hear Biblical content as this is a faith-based program and that I am granting access to FOCUS for the purpose of monitoring my student's grades and academic progress.*
I give permission for my student to have photos or videos taken of them and for these photos to be posted to social media as part of community building and awareness for Avenue941.*
This field is for validation purposes and should be left unchanged.