1399 McAllister Street, San Francisco, CA 94115

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Student Intake Form

SAN FRANCISCO STUDENTS BACK ON TRACK

Student Intake Form 2026–2027

Overall Instructions: Please complete all sections of this form. Do not leave required fields blank. For items marked “select one”, check only one box unless otherwise directed. If a question does not apply, write “N/A”. This form and the attached Parent/Guardian Participation Agreement must both be completed and submitted before the student may participate in the tutoring program.

Student Information

Instructions: Please complete all student information fields. For items marked “select one,” check only one box unless otherwise directed. If “Other” is selected, please specify.

BASIC STUDENT DETAILS

 

School Information

Demographic Information

Race/Ethnicity (select one):

Housing Status (select one):

Home Language (select one):

Parent/Guardian Information

Instructions: Both columns must be completed. If there is only one parent/guardian, use the second column for a backup contact or another trusted adult who can be reached regarding the student. 
PARENT/GUARDIAN 1
Parent/Guardian 2 / Backup Contact

Emergency Contact Information 

Instructions: Please provide an emergency contact who can be reached if the parent/guardian listed above is unavailable. This person should be authorized to discuss the student’s immediate needs in an emergency.

Health Information

Instructions: Please provide any health information that may affect your child’s safety, participation, or need for support during tutoring. Include any medical conditions, medications, allergies, dietary restrictions, or special instructions staff should know. If a question does not apply, check “No” or write “N/A.”

In the event of a medical emergency, San Francisco Students Back On Track will make every reasonable effort to contact the parent/guardian listed on this form. If the parent/guardian cannot be reached and immediate care is needed, I authorize program staff to contact emergency medical services and allow my child to be transported to the nearest appropriate medical facility for emergency care.

Clear Signature

Tutoring Information.

Instructions: Please review the tutoring expectations and schedule below. Check the day(s) your child will attend and complete the attached Parent/Guardian Participation Agreement.

Tutoring Program Expectations: This is a homework-driven tutoring program. Students are expected to bring homework, class assignments, study materials, or schoolwork to each session. Tutors will support students by helping them understand assignments, complete work, and check for understanding. In collaboration with the student, parent/guardian, and teacher, program staff may identify skills that need additional support and include targeted practice activities in the student’s tutoring schedule. 

Parent/Guardian Participation Agreement: Parent/guardian must complete the attached Participation Agreement for additional program details, expectations, and required acknowledgments.

Tutoring Schedule: Tutoring sessions are held on Mondays and Wednesdays from 5:30 PM to 8:00 PM. The program begins Monday, October 5, 2026, and ends Wednesday, May 26, 2027. San Francisco Students Back On Track follows the SFUSD calendar; tutoring is cancelled when SFUSD schools are closed. Sessions may also be cancelled due to church events. Advance notice will be provided whenever possible.

Dinner: Dinner is served for students from 5:30 PM to 6:00 PM.
TRANSPORTATION INFORMATION

Please indicate below whether your child needs transportation support and select the service requested. Pickup is available within a 2-mile radius of the church, and drop-off is available within a 3-mile radius of the church. Transportation seats are limited, so families are encouraged to submit requests early. Service is provided based on availability. Transportation is not confirmed until the request has been approved by the Executive Director. The family will receive confirmation using the preferred contact method selected below and the phone number or email address provided in the Parent/Guardian Information section above

All required intake forms must be completed and submitted before a Transportation Request Form can be requested.

Permissions and Acknowledgments

Instructions: Please read each statement carefully. Parent/guardian must sign and date this section to confirm permission, acknowledgment, and agreement.

I give permission for my child to participate in the San Francisco Students Back On Track After-School Tutoring Program.  

I understand that this Tutoring Intake Form and the attached Parent/Guardian Participation Agreement must both be completed and submitted before my child may participate in the tutoring program.

I understand that program staff may contact me by phone, text message, or email regarding scheduling, attendance, progress updates, program information, or emergencies. 

I give San Francisco Students Back On Track permission to contact my child’s teacher using the teacher information provided on this form and to access my child’s Google Classroom weekly summary, if available, to support tutoring services.  

I understand that regular attendance and timely communication are important to support my child’s participation and progress in the tutoring program.

I agree to notify the program as soon as possible if my child will be absent, late, or unable to continue participating in tutoring.

I certify that the information provided on this form is accurate and complete to the best of my knowledge.
Clear Signature