Teacher Referral Form

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:

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): *

Currently, all one-on-one tutoring for 3rd - 12th graders is being held virtually. Do you believe this student will be able to appropriately engage via Zoom? (All Kinder - 2nd grade students will be prioritized for physical, staff-led tutoring small groups) *

Teacher Referral Form 2020/2021