New Tutoring Request Welcome back for the 18-19 School Year! Any foster child in out-of-home care (foster care, relative care, non-relative care, and group homes) residing in or managed from Orange, Osceola, or Seminole County is eligible to receive funds. Please attached this year's 1st quarter report card or IEP so we may process the request. If you need tutoring for GED or College classes, please click the 'Request Help' button and fill out the appropriate form. Submitter Name* First Last Submitter Email* Relation to Student*GuardianCase ManagerIL SpecialistGALSelfOtherOther Relation:*Student InformationFSFN IDStudent Last Name*Student First Name*Student Other NameDate of Birth* MM DD YYYY Gender*MaleFemaleEthnicity*African-AmericanAsian-AmericanCaucasianHispanic-LatinoMulti-EthnicOtherOther Ethnicity*Parental Rights Terminated?*YesNoPlacement*Foster HomeGroup HomeRelativeNon-RelativeIn-Home Court OrderedIn-Home VoluntaryIn-Home Diversion (CBC Use)Transitional HomePost-Adoption (CBC Use)OtherGroup Home Name*Other Placement:*Is relative receiving relative caregiver funds?*This will not affect approval for funding.YesNoHas the student received any other FFC services?*YesNoNot SureGuardian InformationGuardian Name* First Last Guardian Phone*Guardian Email Is guardian aware tutoring services are being requested?*YesNoAddress where student resides:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Tutoring will most likely be taking place:In-homeAt schoolAt daycareIf possible, please provide days student is available to tutor. Monday Tuesday Wednesday Thursday Friday Weekend Educational HistorySchool Currently Attending*Grade in School*Pre-KK123456789101112Does this student have a mental health diagnosis?*YesNoNot SureIs this student in counseling?*YesNoNot SureHas FSPT packet been completed? (For case management use only)YesNoIs this student in Exceptional Student Education (ESE)?*YesNoNot SureIs this student in English Speakers of Other Languages (ESOL)?*YesNoNot SureDoes this student have an IEP?*YesNoNot SurePlease attach IEP, if available.Number of retentions throughout school history:Please indicate the current educational needs of this student:* Math Reading Science History Other Please indicate the "other" current educational needs of this student:*Please attach most recent grades*If no report card is available, please attach other educational record. *Please note, the request cannot be processed until a report card or educational records are provided.*Does this student have access to a computer and printer where they reside?*YesNoPlease explain why this student does not have access to a computer and printer.*Has this student previously received tutoring?YesNoWith which tutoring agency?Why did tutoring end?Is another student in the home currently receiving tutoring?*YesNoWith which agency?In-Home TutorsClub Z Orange SeminoleClub Z OsceolaCase Manager InformationIs the case likely to close in the next two months?*Most likely yesMost likely noNot SureCase Manager Name* First Last Case Manager Phone*Case Manager Email* Case Management Agency*CHSDEVGCJFCSOHUOtherOther Case Management Agency:*County Case Managed Out of:*OrangeOsceolaSeminoleOtherOther County Case Managed Out of:*Is this an OTI/ICPC case?*YesNoNot SureCase Manager Supervisor Name First Last Supervisor PhoneSupervisor Email Guardian Ad Litem InformationGAL Name First Last GAL PhoneGAL Email Student will send a "Thank You" card/letter within 2 weeks of receiving services. I Agree CommentsThis field is for validation purposes and should be left unchanged.