Student Enrollment Form

Children’s Literacy Center, a 501(c) 3 non-profit community organization, provides individual assistance to students who are reading below their grade level. Our phonics based curriculum is appropriate for children who have completed the fall semester of first grade and are reading between the first and sixth grade levels. The Peak Reader® Program is not appropriate for children who have been diagnosed with Dyslexia, have an Individual Education Plan (IEP), or do not speak English fluently.

Enrollment is available at no cost to families.

Our tutors are community volunteers who undergo an application and background screening process and are trained to use the Peak Reader® Program. A qualified site coordinator is present during all tutoring sessions.

Once this form and the Teacher Referral Form have been submitted, your child’s name will to added to our wait list until we have an available tutor. 

All of the information shared in this document is kept confidential and is only for Children’s Literacy Center’s use. 

Child's Name(Required)
MM slash DD slash YYYY
Parent's/Guardian's Name(Required)
Address(Required)

Please briefly describe any medical and/or support services you child receives:

This information is kept confidential and is only for Children's Literacy Center's use. 

Select the location at which you would like to have your child tutored:

Location(Required)

Please check the appropriate answer to assist our staff with providing accurate information when applying for grants in support of our program (this information does not determine your child’s enrollment in our program):

Does your child qualify for free or low-cost lunch program?(Required)
Is your child a military dependent?(Required)
Is English the primary language spoken in the home?(Required)
How did you hear about CLC?(Required)
Please check one of the boxes below to indicate whether you grant CLC permission to use your child’s image in CLC’s marketing materials.(Required)
Consent(Required)