P R O G R A M R E G I S T R A T I O N F O R MDue Friday, October 12th 2012

(Drop off this form at your Guidance Office)

PARTICIPANT INFORMATION

Last Name: First Name:

Date of Birth: Grade: Name of School:

Address Day and Evening Tel: Email Address (You must provide a valid email address):

SUBJECT OF INTEREST

Which one of the following areas do you need tutoring with? Please circle your choice.MATH SCIENCE ENGLISH

Which one is your first choice? ______________________ second choice? _______________________What is your subject code? (e.g. SPH4U0 for Grade 12 University-bound Physics)First choice _____________________________ Second choice ___________________________

PARENT/GUARDIAN INFORMATION

Parent/Guardian's Name:

Home Number: Work Number:

Emergency Contact Name:

Home Number: Work Number:

Total Household Income (Please Check One): Up to $40,000 per year. Greater than $40,000 per year.

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Are there any circumstances that you would like us to consider when considering your application to the program? If yes, please briefly describe your situation in the space provided below:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________ _______________________________Student’s Signature Date Signed

PARENT/GUARDIAN CONSENTFor students under 18 years old only

I _________________________________, permit my child, _____________________________, (Print your name here) (Print your child’s name)to meet with his/her tutor from Project: Universal Minds after school at a designated room in

his/her school. If the school has no supervision available after class, I will allow my child and

his/her tutor to meet at ___________________________________________. If necessary, I will

meet with my child’s tutor to discuss his/her academic difficulties or provide any help required for

his/her success in the program. I understand that if my child misses two (2) sessions for no valid

reason, he/she will be expelled from Project: Universal Minds.

________________________________________ _________________________ Parent/Guardian’s Signature Date

Please note:If tutoring is not available at the high school of your child, the Arts and Science Students’ Union allows its tutors to meet with their students at a public venue such as public libraries, community centres or coffee shops close to the high school. Tutoring cannot be conducted in your home at any time.

For Guidance Office Use Only:Do you strongly recommend this student? Yes NoStudents’ Mark in his/her first choice of subject: _________ second choice: __________Additional Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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________________________________________________________________________________

Teacher/Guidance Counselor’s Name: _____________________________ Date: _____________

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