Reading and Writing Clinic Registration

Student Name*
Please enter the first, middle, and last name of your elementary student in the order requested.
First Middle Last
Child's Nickname or Preferred Name
Does your child go by a nickname? If so, please list.
Student Date of Birth*
MM slash DD slash YYYY
Name of Student's School*
Please list the full name of the school the student attends.
Name of Student's School District*
Please write in the full name of the school district that the student attends.
Name of Student's Parent(s) or Guardian(s)*
Please enter the name of legal guardian or parent.
Student's Legal Address*
Please list the complete address with street, town add zip code

Street Address City State ZIP Code
Best Phone Number for Parent/Guardian
Parent Email*
Why would you like your child to attend the Reading and Writing Clinic at Monmouth University?*
Expected Attendance
If your child is enrolled in the Reading/Writing Clinic, s/he is expected to attend every day that the Clinic is in session. Are there any days that he or she would not be able to attend? If so, please list below.
Student's Grade*
- Kindergarten
- First
- Second
- Third
- Fourth
- Fifth
- Sixth
- Seventh
- Eighth
- Freshman/Nineth
- Sophomore/Tenth
- Junior/Eleventh
- Senior/Twelth
What is your child's first language?*
Does your child speak another language/s? If yes, please state language/s.
Which language is most often spoken at home?*
What are your child's interests?*
What does your child do well?*
How would you describe your child's interest in reading and writing?*
How often does your child read at home?*
What does your child like to read about?*
Can you name the title of a book your child read at home alone or with a family member during the last two weeks?
Does your child usually read alone or with another family member?*
How often does your child write at home?*
Does your child usually write alone or with another family member?*
What does your child like to write about?*
If your child is enrolled in the Reading and Writing Clinic, we may want to contact your child’s teacher to gather additional information about your child’s reading and writing needs. Name of Child’s Teacher*
School Phone Number*
Teacher's Email Address*
Permission to Contact Child's Teacher*
If my child is enrolled in the Reading and Writing clinic, I give my permission for the Monmouth University Reading and Writing Clinic to contact my child’s teacher and discuss his or her performance and progress in reading and writing. I give permission for the Monmouth University Reading Clinic to request from the teacher any written documents pertaining to my child’s reading and writing performance during the present school year or any previous school years, and to use this information for teaching purposes. All information will be held strictly confidential. At the conclusion of the Reading and Writing Clinic, I understand that a copy of the report of my child’s performance during the Reading and Writing Clinic may be shared with my child’s teacher.
- Yes, I agree and give permission
- No, I do not agree and do not give permission
Permission for Child's Temperature Check at Drop Off*
If my child is enrolled in the Reading and Writing clinic, I give my permission for the Monmouth University Reading and Writing Clinic to take my child’s temperature at drop off. If my child’s temperature is above 100.4, I understand my child will not be able to stay for the clinic. I also understand that I must be able to provide my child with a mask. They will be required to wear this mask for the duration of each session.
- Yes, I agree and give permission
- No, I do not agree and do not give permission
Name
This field is for validation purposes and should be left unchanged.

Registration Form