Student Enrollment Form

Children’s Literacy Center, a 501(c) 3 non-profit community organization, provides individual assistance to students who are reading below their grade level. Our phonics based curriculum is appropriate for children who have completed the fall semester of first grade and are reading between the first and sixth grade levels. The Peak Reader® Program is not appropriate for children who have been diagnosed with Dyslexia, have an Individual Education Plan (IEP), or do not speak English fluently.

Enrollment is available at no cost to families.

Our tutors are community volunteers who undergo an application and background screening process and are trained to use the Peak Reader® Program. A qualified site coordinator is present during all tutoring sessions.

Once this form and the Teacher Referral Form have been submitted, your child's name will to added to our wait list until we have an available tutor. 

All of the information shared in this document is kept confidential and is only for Children's Literacy Center's use. 

 

Please briefly describe any medical and/or support services you child receives:

This information is kept confidential and is only for Children's Literacy Center's use. 

Select the location at which you would like to have your child tutored:

Location

Please check the appropriate answer to assist our staff with providing accurate information when applying for grants in support of our program (this information does not determine your child’s enrollment in our program):

Does your child qualify for free or low-cost lunch program?
Is your child a military dependent?
Is English the primary language spoken in the home?

Consent to Image Release

On occasion, reporters, staff, board members or parents may visit the tutoring site to produce articles on Children’s Literacy Center, which may be published in the newspaper, on television, posted on the CLC website or social media. Please note that our policy is to never release student names to reporters. In addition, no student is ever identified by name in any photograph bearing his or her image on our website or social media. 

Please check one of the boxes below to indicate whether you grant CLC permission to use your child’s image in CLC’s marketing materials.
Please do not publish my child’s image in any publication.
I consent to the release of my child’s image in publications referencing Children’s Literacy Center or the Peak Reader Program® in whatever way the Children’s Literacy Center shall choose. With this consent I agree that neither I nor my child shall receive any fee and that all rights, title, and interest of the images and use of them belong to the Children’s Literacy Center. I further release and indemnify Children’s Literacy Center, its directors, employees, staff, volunteers, and other agents from and against any and all liability and responsibility for any claim or cause of action on account of any damages, expenses, or other loss caused, suffered, or occurred during, arising out of, or in any way associated, directly or indirectly with my child’s appearance in the photographs, the make of such images, and/or their use.
Parent Commitment
Parent/ guardian commitment and support are critical to your child’s success. Therefore, you must abide by the requirements listed below for your child to participate in the Peak Reader® program.
  • Attend a mandatory parent orientation
  • Arrange for your child to be dropped off and picked up on time
  • Read for at least15 minutes a day with your child, and keep a reading log which is provided by the site coordinator or tutor
  • Provide an update on the status of your child's educational needs
  • Complete Children's Literacy Center program survey
Consent to Share Assessment Results
  • In order to demonstrate the success of the Peak Reader Program, I understand that CLC will publish student assessment results on its website, grant proposals and other publications so that I, as well as other interested parties, will have access to this information.
  • I understand that Children’s Literacy Center (CLC) will protect my child’s privacy and his or her name will never be revealed when assessment data is shared.
  • I understand that student growth data may be used to make comparisons in gender, the length of time a student has been in the Program, grade level, etc.

I am the child’s parent or legal guardian. I have read this document and by submitting it I am signing it freely and voluntarily. For the benefit of the Children’s Literacy Center, I acknowledge that my child is participating in the Peak Reader Program offered by the Children’s Literacy Center. I understand that my child’s participation in the Program is subject to any and all rules, procedures, and requirements established for the Program, and by the Children’s Literacy Center personnel, tutors, and any other person(s) conducting, leading, and /or directing the activities involved in the Program. I hereby release, forever discharge, and indemnify Children’s Literacy Center, its directors, employees, staff, volunteers, and other agents from all liability and responsibility for any personal injury, accident, damage, expenses, or other loss caused, suffered, or incurred to me or my child during, or arising out of, my child’s participation in the Program. Further, I acknowledge that I have read and understand the legal consequences of the above statements, and that if I am unable to do so for any reason I have had them read to me and am confident that the individual has read and/or translated the statements truthfully and in their entirety. This release and waiver has been executed on behalf of me and my child, with full knowledge and assumption of possible risks involved in the Program and any events incidental to the Program, and with the understanding that I am waiving my right to sue the Children’s Literacy Center. This instrument has been executed in and shall be interpreted according to Colorado law.