Teacher Referral Form

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What We Do
How to Help
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Teacher Referral Form 2018/2019

* Indicates required field

Teacher Name *

First

Last

Teacher Email *

Student's Name *

First

Last

Student's Grade *

Student's age *

Student's gender *

Female Male

Which TLC program are you nominating this student for *

Tutoring Enrichment Family Literacy

School *

MMES JES Colter Wilson JHMS Other

Priority (1 being the highest) *

1 2 3 4 5

Parent Contact *

First

Last

Parent Phone Number *

Parent's preferred Language *

English Spanish Other

If not English, indicate English proficiency *

None Limited Conversational

Have you spoken with this student and his/her parents about TLC programs? *

Yes No

To nominate a student for TLC, you must have made contact with the family and/or return this form with a parent application form. Does TLC have permission to contact this family? *

Yes No

The child is being referred for assistance primarily for the following reasons, please check all that apply and explain:

Academics *

Reading Writing Attitude about school/education Organizational Skills/ turning in assignments Other

Family *

Family Support Family Changes Other

Behavior *

Classroom Behavior Bullying Self Esteem

Social Skills *

Communication skills Peer Relations Other

Please Explain your above choices *

Reason why this child might benefit from tutoring or enrichment *

What non-academic interests, either in-school or out, does the child have? *

Additional comments (if necessary): *

Submit

307-733-9242 • info@tetonliteracy.org • PO Box 465 • 1715 High School Rd. #260 Jackson, WY 83001