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Student Information

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* 1. Student First Name

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* 2. Student Last Name

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* 3. Grade (2020-21)

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* 4. School

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* 5. Teacher

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* 6. Child's CMS ID Number

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* 7. Child's Birthdate

Date

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* 8. What type of device will your student be using for tutoring? (Select all that apply)

Parent or Guardian Information

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* 9. Parent or Guardian Contact Information

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* 10. What is the best form of communication for scheduling, reminders, etc.? (select all that apply)

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* 11. When is the best time to reach you using the communication selected above? (select all that apply)

Parent or Guardian Consent
Heart Tutoring 2020-21 Parental Consent Form
Heart Tutoring Privacy Policy

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* 12. Do you give permission for your child to participate in and be assessed by Heart Math Tutoring? (Your consent is REQUIRED for participation in program.)

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* 13. Do you give permission for Charlotte-Mecklenburg Schools to release the following data for your child to Heart Tutoring for the purpose of demonstrating the effectiveness of the program? (This consent is REQUIRED for participation and remains in effect until notification from a parent or legal guardian is received by this agency notifying the agency to discontinue services and program involvement, or the student graduates and/or leaves Charlotte Mecklenburg Schools)

  • Demographic data (that is, gender, race/ethnicity, grade level, school name)
  • Limited English Proficiency (LEP) Status
  • Exceptional Children (EC) and/or Gifted (AIG) Status
  • Course Grades
  • Standardized Test scores, levels, proficiency (that is, beginning, middle and end of year district state tests)
  • Attendance Data
  • Behavior data (suspensions)
  • Promotion/Retention
  • GPA (High School Students Only)
  • Graduation Status (High School Students Only)
  • Credits Earned and Credits Attempted (High School Students Only)

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* 14. Do you give Heart Math Tutoring permission to use and/or reproduce photographs, videos, likeness or the voice of your child for marketing and informational activities of the program? (Names will not be used, and photo consent is not required for participation in program.)

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* 15. Do you give Heart Math Tutoring permission to share student names and tutoring times with other community partners including HELPS and Augustine Literacy Project? (Not required for participation in the program)

I certify that I am at least 18 years of age and am the parent or legal guardian of the student identified above. By checking the box below, I consent to have my child participate in Heart Math Tutoring’s online tutoring programming and to my child’s use of third party online video and educational platforms, such as Google Meet and Jamboard, as conferencing tools, with sessions recorded. I have read the Heart Tutoring privacy policy, and I certify that I consent to the collection, use and/or disclosure of my child’s personal information in accordance with Heart Tutoring’s privacy policy.

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* 16. Parent or Guardian Confirmation

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