Student Application Page # 1 of 2
Photos: left to right: Cleophas McAlpin, Executive Director: Students: Dentist Doctor Beale teaches : M.D. Doctor Browne teaches.
Application below must be completed before admittance to Program. Please print out this page and complete Application.
"A Free Tutoring Service Preparing for the Future"
A State of California and Federal Nonprofit Corporation
Please complete this application, as well as the Authorization page (page 2: print out page and complete) that gives Mr. Cleophas McAlpin permission to meet with School Counselors and Teachers. Return application to Mr. McAlpin as soon as possible.
Name_____________________Today's Date_________
Date of Birth____________Age________
Name of Parents___________________
Telephone Number_________________
Church Affiliation (Optional)_______________________
School Information
Name of School____________________________
Telephone Number of School__________________
Grade Level__________________Current G.P.A.(If Known)_________________
Names of Teachers and Subjects_________________________________________
_________________________________________________
Emergency Information
Health Provider______________________________
Telephone Number____________________________
In Case of Emergency: Call______________________
Relationship_______________________
Telephone Number______________Or__________________
Other Important Information: Income Level of Parent or Guardian ***
Check One: Extremely Low______Low_____Moderate______
Ethnicity (Optional)_________________________________
**See Worksheet Provided by Tutoring Service for Income Level Classifications