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Student Application

Student Name *

First

Middle

Last

Student Age *

Student Birth Date *

Parent/Legal Guardian Name *

First

Last

Address *

Street Address

Address *

City, State & Zip

Phone Number *

Email *

School District

Would you like to receive monthly school district updates? *

Student Education Level *

Current Grade *

Previous State Testing Reading Score *

Used to determine tutoring eligibility. (Example: Florida - FCAT)

Previous FCAT Math Score *

Used to determine tutoring eligibility. (Example: Florida - FCAT)

Previous Disciplinary Issues *

If none, please indicate with N/A. If so, please explain.

Would you like to participate in our mentoring program? *

Select up to two choices.

Any known health conditions or allergies of student? *

Is/Will student be a first generation college student?

If a higher-ed Collegiate student, which level are you?

Select one.

Website

Pearls of Grace, Inc. is a 501(c)4 civic and social awareness organization. Donations are not tax deductable.

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