Teacher Referral Form

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

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

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): *

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

Teacher Referral Form 2018/2019