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Dear Parent,


We are pleased to inform you that your child has been considered to participate in a free after-school and/or summer tutoring program called Reading for Change! RFC is a local, free reading program that takes place at 105 South Market Street (top floor) in downtown Troy. RFC is focused on helping your child grow academically as well as in all areas of life. The program consists of structured, one-on-one tutoring through committed, stable and encouraging relationships with supportive adults. It also includes homework help, a number of reading activities, and a hardy snack. Each RFC student is evaluated periodically throughout the school year to access whether the RFC program is meeting his/ her needs.


RFC’s reading tutors are trained volunteers that come from our community. RFC takes all of its volunteers through a comprehensive background security check. Additionally, all tutoring will take place in a group environment and no child will be left alone with an adult volunteer. It is important to the program’s success that your child attends RFC at the proper time and is not picked up before we are finished with our session.


We have included in this packet an application for registering your child for RFC. If you are interested in your child taking part in this free reading program, please completely fill out the form below. You will be notified if your child has been accepted into the program.


By signing submitting this form, you also give the faculty of Troy City Schools permission to discuss your child’s grades, scores, and progress with the program director. This is an important factor so we can best help your child by working with teachers to focus on your child’s individual needs. Our commitment is to make sure this will be done in a confidential manner.


If you have any questions about the program or the application, you can contact me at 937-239-8350 or Thank you! We look forward to working with your child and helping him or her succeed in school!


Please turn in your application as soon as possible to ensure your child has a place in the program!

Carianne Cheatwood

Program Director

Student Application

What your child is registering for:

Parent/Guardian 1

Emegency Contact

Parent/Guardian 2

Emegency Contact

Additional Contact

Emegency Contact

Participation Consent, Waiver, and Release

I                                                                            give my child

permission to participate in the RFC tutoring program offered during the current school year (the “Program”). By signing this document, I am documenting that I understand and agree to each of the following statements .

Communication with school: Members of the faculty at my child’s school may discuss my child’s grades, score and progress with his/her Program Director. This will always be done in a confidential manner.
Emergency Medical Treatment: If my child becomes seriously ill or injured while participating in the Program, any authorized member of RFC may seek and obtain emergency medical treatment for my child as he or she deems necessary.
Faith-based activities: I acknowledge that the Program may utilize some faith-based materials. My child has permission to participate in faith-based activities as they may be offered during the Program.
Publicity: RFC may use my child’s name and/or photograph(s)/video for the purposes of duplication, publicity and/or publication.
Transportation: RFC provides no transportation to or from the facility. It is the guardian’s responsibility to provide transportation and/or approve for the child to walk to RFC and then home. By signing this consent, you are giving your child permission to walk to RFC from school and/or home. If you need to notify your child of any changes regarding getting home from RFC, please call 937-552-2484.
Attendance: Your child is expected to attend regularly once granted acceptance into the program. If your child has more than 3 unexcused absences, he/she will be given a warning and RFC will contact child’s guardian. After 5 unexcused absences, your child will be asked to leave the program.

Acknowledgement of Understanding: I have read this Consent, I understand the terms used in this Consent and have willingly placed my signature below as evidence of my acceptance of all the conditions stated in the Consent. I sign this Consent with the understanding that I, for my child and for me, am giving up any right to legal recourse against RFC for negligent conduct (but not for reckless or intentional conduct) in return for allowing my child or me to participate in Program activities. I understand that this Consent applies each and every time, and remains in effect for as long as my child or I participate in any Program activities. Because I am signing this Consent on behalf of a minor, I certify that I am my child’s custodial parent or legal guardian with full authority to act on my child’s behalf with respect to everything addressed in this Consent.

Emergency Medical Treatment Authorization

Purpose: To enable a custodial parent or guardian to authorize emergency medical treatment to his or her student if the student becomes seriously ill or injured while participating in the RFC’ Tutoring Program and the custodial parent or guardian cannot be contacted.

Directions and Consent

1. If my student seems to need emergency medical treatment, I direct that my student be transported to a nearby hospital.
2. If, after arranging for my student’s transportation to a nearby hospital, reasonable efforts to contact me are unsuccessful,
I then direct that reasonable efforts be made to contact at least one of the medical care providers listed below.
3. If neither I nor either of the medical care providers listed below can be successfully contacted to discuss emergency medical treatment for my student,
I consent to any emergency medical treatment considered necessary by the medical care personnel treating my student. This consent to emergency medical treatment does not authorize surgery unless before the surgery, two physicians agree that surgery is necessary (one of whom must be one of the medical care providers named below – but only if available).

Medical care provider

Facts about my students medical history

Does your student have any physical disabilities?
Is your student currently taking any medications?
Does your student have any dietary allergies or restrictions?
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