Back to Access Programs First Name Last Name Driver's License Number Driver's License State Address or CMB Number Phone Number ###-###-#### Email Address Major Year you will graduate Have you ever been a tutor before? Yes No If yes, what age group and what subject? Is there a subject you prefer to tutor? Do you have any previous experience working with 7th - 12th graders? Yes No Please list the courses you are taking and your grade for each class. Signature Tutoring involves establishing a mentoring relationship with a young student to encourage their academic goals and behaviors. Besides being required to uphold the University of Puget Sound codes of conduct you are also agreeing to the following: I will work closely with Tacoma Public School teachers, parents/guardians, my assigned student, and the Access Programs Coordinator to identify and meet the academic needs of the student assigned to me; I will attend regularly scheduled weekly tutoring sessions on the University of Puget Sound campus; I understand that on-going training is a requirement of the program and I will attend all workshops per notification of the program coordinator; I will immediately notify the Access Programs office of any problems which might occur between me and my assigned pre-college student or his/her family or if my personal circumstances should change such that I will be unable to fulfill my obligations in accordance with the program requirements. I understand that if I do not comply with these requirements I may be in jeopardy of being removed as an Access Programs tutor. Signature Pad I understand this is a legal representation of my signature. The Access Programs Department is under the Office of Diversity and Inclusion, and serves first-generation college students, students of color, and/or students with a low socioecomic status. What is your experience with one or more of these student populations? How might these experiences reflect how you tutor and build relationships with our students? Please tell us anything about yourself you would like us to know (special interests, ideas for field trips, etc.) Implementation of the Student Integrity Code It is important for the children and families involved in Access Programs and the University of Puget Sound that our students represent the university in a positive manner. Students who have been placed on conduct probation are not permitted to participate in Access Programs during their probationary period. Previous involvement in the integrity code process could also have an impact on your participation. Pursuant to the Family Educational Right and Privacy Act (FERPA) and University of Puget Sound policy, the Division of Student Affairs does not release personally identifiable educational information and/or records without the written permission of the individual involved. I hereby authorize the disclosure of information concerning myself and to discuss materials and opinions if necessary to that information to University of Puget Sound's Access Programs. Any information obtained will be directly released only to the Access Programs Coordinator. Signature Pad I understand this is a legal representation of my signature.