Student Registration

Student Registrationmasonjames2024-05-22T15:27:49+00:00

"*" indicates required fields

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*

First Last

Parent/Guardian Email Address*

Parent/Guardian Phone*

Parent/Guardian Address*

Street Address Address Line 2 City State ZIP Code

The best way to reach me is*

Where or from whom did you hear about this opportunity?*

Choose Desired Semester*

Location I want to register my student for:*

Please list the names and phone numbers of all the people who have your consent to pick up your student:*

What other contact information do we need, if any? (List names with phone numbers)

Student Information

Students

Student Name	Actions

There are no Students.

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?*

Yes, for my student

Yes, for my 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.*

Food Services

Pregnancy Services

Substance Abuse Services

Transportation Services (outside of this program)

None

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.*

Yes

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.*

Yes

This field is for validation purposes and should be left unchanged.

Student Registration

Student Registration

Parent/Guardian Information

Student Information

Academics | Discipleship | Counseling

Contact Info

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