America Reads and America Counts

Tutor Application

Name:____________

First Middle Last

Address: ______Street City State Zip

Phone: ______Student ID______

Email Address: ______

Which program are you interested in tutoring with? ______Reads ______Counts

Are you applying for a work-study position? ______Yes ______No (In order to qualify for work-study, you must have a work-study award from the financial aid office).

  • If yes, are you willing to commit to both fall and spring semesters? Yes No
  • If we are unable to offer you a work-study position, do you want to be considered for a volunteer position? Yes No

Do you prefer to work with a particular grade level? If yes, which grade? ______

What transportation do you plan on using to reach your school? ______

PREVIOUS WORK / VOLUNTEER EXPERIENCE

EmployerPosition SupervisorPeriod of Time Worked

______

______

______

PERSONAL REFERENCES

Name three people not related to you who have knowledge of your qualifications to work effectively with children. We will be contacting at least two of the three references.

1) Name:______Relation:______

Phone: ______

2) Name:______Relation:______

Phone: ______

3) Name:______Relation:______

Phone: ______

How did you hear about America Reads or America Counts? ______

______

Please Circle Preferred Program

Name: Reads / CountsWork Study? Y / N

On the following form please shade in the boxes that you ARE available for tutoring. Make sure to allow time for travel to and from the school.

Monday / Tuesday / Wednesday / Thursday / Friday
8:30-9:00
9:00-10:00
10:00-11:00
11:00-12:00
12:00-1:00
1:00-2:00
2:00-3:00 / 2:30 Early Out
3:00-3:30
After School
Homework Club

What are the maximum number hours you prefer to work? _____

A number of Missoula schools are located a few miles from campus. Indicate which schools you CANNOT get to by putting a check next to the name(s). The greater the number of schools you can travel to the higher the probability of placing you.

____ Paxson (University Area on Higgins)

____ Lowell (North Side of Missoula next to Scott’s StreetBridge)

____ Chief Charlo (South Hills)

____ Lewis & Clark (Park Street--5 blocks from Dornblazer Field)

____ Franklin (5 blocks West of Russell Street)

____ Russell (Next to the Fair Grounds)

____ Hawthorne (off of Reserve)

Note: As of Jan. 2009, we will run a sex-offender registry check on all America Reads America Counts tutors.

Please have this application notarized before submitting. See Ellen Flanery at ASUM Legal Services (UC112) 9-3:30 for free notarization or Campus Quick Copy (UC 1st FL) ($3).

SECTION 20-4-110 FORM

Student’s Identification Number:______

Name:______

(last) (first) (middle)

Section 20-4-110 of the Montana School law give the Board of Public Education the authority to suspend, revoke or deny certification of any person who (a) has been convicted of a crime more serious than a minor traffic accident, (b) makes any statement of material fact in the application for a certificate which the applicant knows to be false, (c) has been denied, had revoked, suspended, or has surrendered teacher or specialist certification in another state, or (d) is guilty of immoral conduct related to the teaching profession.

A “yes” answer on one or more of the questions that follow will not necessarily eliminate you as a candidate for a Montana teacher certificate. However, this form is designed to serve as an initial screening device to identify candidates from whom further information is needed to make professional judgments related to the implementation of the codes for Montana schools.

___Yes ___No1.Have you ever been convicted of a misdemeanor

other than a traffic violation?

___Yes ___No2.Have you ever been arrested, indicted, or convicted

on a felony charge?

___Yes ___No3.Have you ever been denied admission to a teacher

education program?

___Yes ___No4.Have you ever been removed (for any cause) from a

teacher education program?

___Yes ___No5.Have you ever had a teaching certificate denied or

revoked in any state?

I attest that the responses I have made to the above questions are true statements, and I understand that falsification may be considered sufficient cause for my removal from the teacher education program or ultimate denial of my teaching certificate.

(Sign in front of notary)______

Applicant’s Signature

State of ______

County of ______

Subscribed to and sworn to before me this ______day of ______, 20______

at ______.

______

Notary’s Signature