2019-2020 Neighborhood Tutoring Program Student Application 

Page 1

Logo and header image
Dear Parent(s) / Guardian(s):  Thank you for your interest in For Love of Children (FLOC).  FLOC provides FREE educational services beyond the classroom to help students succeed from first grade to college and career. FLOC is currently accepting applications for 2019-2020 School Year for The Neighborhood Tutoring Program.

Please visit this page for more information regarding the Neighborhood Tutoring Program. You will be contacted with the next steps within two weeks of your student's application being submitted.

Application Checklist


In order for your student to be considered for FLOC participation:

  • We must received a completed application
  • Your student must attend a testing session so that we can determine their eligibility for the program (you will be invited to schedule a testing session date after your application is reviewed). During the same session the parent needs to be present to review all policies.
  • Show proof of eligibility for FDPIR, TANF, SNAP, or Medicaid card. (Must provide even if the student is in FLOC programs already).

We must receive the following documents IF your student is receiving supplemental services at school:

  • Individualized Educational Plan (IEP)                      
  • Functional Behavior Assessment
  • Behavior Intervention Plan
  • 504 Plan


If you are unable to upload any of the additional documents in this form, please submit them to:

Recruitment & Outreach                     

Email: rando@floc.org              

Fax: (202) 462-9280         


Page 2

2019-2020 Neighborhood Tutoring Program

Page 3


Does your student have any of the following plans to receive supplemental services or accommodations at school?

Page 4

This secondary contact can be additional parent/guardian, relative, neighbor,etc.
EMERGENCY CONTACT INFORMATION (Required - must be someone other than parent / guardian)  
This information will be used to process a student's application and for FLOC's statistical reports to organizations that make donations to the FLOC program. All of your responses will be kept confidential.
*Please note: If you did not file taxes in 2018, please provide the best estimate of your household income, including TANF, SDI / Social Security, retirement, child support, alimony, etc. 

Page 5

I certify that the medical information provided above is accurate to the best of my knowledge. I understand that FLOC will not allow my child to take medications not listed on this form without direct consent from a parent / guardian. I understand that I am required to give medical consent in order for my child to participate in any FLOC program(s).


This form is required. This page MUST be completed and signed by the student's legal parent or guardian

Medical Authorization
I grant permission for a representative of For Love of Children to have my child treated at an appropriate facility in the case of an emergency while my child is in attendance at a For Love of Children program. I understand that representatives of For Love of Children are not medical professionals and will only seek medical assistance from a licensed medical facility in case of emergency when I cannot be reached. I waive my right to prosecute any representative from For Love of Children who proceeds as above.
Report Cards, Standardized Test Results, and Education Plans
I grant permission for a representative of For Love of Children to request and receive copies of my child’s report cards, transcript, standardized test results, and supplemental education plans (IEP, behavioral plans, etc.) from my child’s school.
Other Service Providers
I grant permission for a representative of For Love of Children to communicate with other agencies/service providers who are providing assistance to my child, including school counselors, teachers, social workers/case managers, or other non-profit agencies. I understand that FLOC will be communicating with these providers in order to better coordinate services to help my child, and that information about my child will not be shared with anyone outside of the providers, FLOC staff, me, and/or other legal parents or guardians.
Dismissal From Program
Media, Photography, and Video
I understand and give permission to For Love of Children and approved partners to use information about my student's involvement and progress in program as well as photos or video of my child for use as FLOC deems appropriate for publicity and fundraising purposes. I understand that FLOC will keep my child’s name confidential unless I give permission for use of my child’s first name for publicity purposes (or with photos or video) by answering “Yes” to the following question.
Please note: For Love of Children will contact you directly for permission if we ever wish to use your child's full name (first and last) for publicity or fundraising purposes.
I have read and understand all of the above and want my student to be considered for participation in FLOC.

This form is required. This page MUST be completed and signed by the student's legal parent or guardian

FERPA Participant Consent Form 

Education records are considered confidential documents protected by the Family Educational Rights and Privacy Act (FERPA), a federal law designed to protect the privacy of, and provide access to, student education records. FERPA gives parents, legal guardians and students age 18 and older certain rights with respect to their education records, including, but not limited to:
  • The right to inspect and review education records within 45 days
  • The right to seek to amend education records
  • The right to have some control over the disclosure of information from education records
I authorize and consent DCPS Office of the Chief of Staff and/or my child's school to provide information concerning the education of my child to For Love of Children and United Way of the National Capital Area. I further authorize the release of educational records of my child for the current school year to the parties listed above that include the following information: education transcripts, school/program enrollment information, universal student ID, attendance data, credit history, grades, assessment data, IEP information and graduation attainment (12th grade only). This authorization and release shall remain in effect from August 1, 2019 – July 31, 2020.


By signing below, 1) I acknowledge and understand that I have the opportunity to review the records to be disclosed and the right to challenge the contents of such records; and 2) I am at least 18 years of age or I am signing this document on behalf of my child because he/she is not 18 years of age.                                                                        


For Love of Children (FLOC) is funded by the Office of Out of School Time Grants and Youth Outcomes (OST Office), a D.C. Government agency through United Way of the National Capital Area. As a grantee we are required to share participant information with the OST Office that may be collected on this form.


In addition, we are required to administer a questionnaire called the Survey of Academic and Youth Outcomes (SAYO). The SAYO is a brief survey with questions about what your child thinks of the program and of the potential benefits from attending the program. All information collected through the SAYO is confidential and no individual child or their individual responses will be identified. Participation in the SAYO is voluntary. 

By signing below I give permission for my child to be included in the SAYO survey. I further authorize For Love of Children to provide name and date of birth to the OST Office.

  • I certify that the above information is accurate to the best of my knowledge.
  • I understand that my student is being considered for admission into For Love of Children program(s) and that submitting this application and attending testing does not guarantee my child a place in any FLOC program.
  • I understand that before my student will be considered for any FLOC program, I must submit all required documentation (application, proof of income or eligibility and any applicable supplemental education plans required for enrollment by FLOC.)

Page 6


PARENT AGREEMENT (Must be signed)

As a parent / guardian, I: 


Confirm that I have received a copy of the FLOC Attendance Policy.  I understand that I must contact FLOC at least 2 hours prior to the start of programming.  I agree to encourage my student to have regular and punctual attendance. I understand that repeated tardiness or excessive absences (2) will result in my student being removed from the FLOC program(s).  


Confirm that I have received notice of FLOC’s policy on outside food and the electronics / cell phone policy (as outlined above), and am aware that failure to abide by this agreement may lead to the termination of my child from the FLOC Program.


I give permission for my student to participate in FLOC programs

Appropriate Behavior at FLOC 


Be Respectful.  Follow the instructions of FLOC staff and volunteers.  Respect the space and belongings of other students.   

Be Kind.  Keep your hands to yourself except to help someone.   

Be Responsible.  Always be an active participant in your FLOC program(s).  The more effort you put into your FLOC activities, the more you will learn and have fun.   

Be Considerate.  What you do impacts not only you, but those around you.  Make sure you’re helping to create a positive learning environment.  


FLOC’s No Tolerance Policy 


The following behaviors will result in permanent dismissal from FLOC program(s). 


Possession or use of a weapon / weapon look-alike. 

Possession of / being under the influence of drugs, alcohol, or tobacco.   

Physical fighting of ANY kind (including rough-housing). 

Threat or intent to harm another participant and / or staff member with an object being used as a weapon.  

Physical or sexual harassment of another student or staff (ex:  inappropriate touching, sexual language used). 

Blatant disrespect / defiance 


Parent & Student Agreement Form