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Intake form
Student Interest Form
Child’s Full Name
*
Date of Birth
*
Grade Level for (2025-2026 school year)
*
School Name
Does your child have an IEP or 504 Plan? If yes, please describe any specific accommodations:
Does your child receive any additional reading support at school or through another program? (If yes, please specify)
Parent/Guardian Name
*
Parent/ Guardian Email address
*
Phone number
*
Preferred Method of Contact
*
Please select at least one option.
Call
Text
Email
Which community center or organization is your child affiliated with? (Select one)
*
Select
Boys & Girls Club of Vista
Armed Services YMCA – Camp Pendleton
Liberty Military Housing
Solutions for Change
Operation Hope
Interfaith Community Services
Other
Which (8-week) session are you interested in? (Select one or more)
Please select at least one option.
25' Summer Session (Between June- August)
25' Fall Session 1 ( August 25- October 17)
25' Fall Session 2 (October 20- December 12)
26' Spring Session 1 (January 20- March 13)
26' Spring Session 2 (March 16- May 15)
Preferred Tutoring Format
Please select at least one option.
In-Person
Virtual
Best Days for Tutoring Sessions (Check all that apply)
Please select at least one option.
Monday
Tuesday
Wednesday
Thursday
Friday
Best Time Availability (Check all that apply)
Please select at least one option.
Morning (9 AM - 11 AM)
Afternoon (12 PM - 3 PM)
Evening (4 PM - 6 PM)
What reading challenges is your child experiencing? (Check all that apply)
Please select at least one option.
Difficulty sounding out words (decoding)
Trouble recognizing common words (sight words)
Reading fluency (reading smoothly & quickly)
Difficulty understanding what they read (comprehension)
Spelling difficulties
Writing challenges
Has your child been diagnosed with any learning differences (e.g., dyslexia, ADHD)? If yes, please specify
How did you hear about We Strive for Literacy?
Select
ASYMCA
Liberty Military Housing
CSUSM
Event
Online Search
Social Media
Word of Mouth
Other
Would you be interested in learning more about future literacy workshops or parent support resources?
Select
Yes
No
📌 Next Steps: Once you submit this form, our team will reach out to confirm your child's enrollment with the chosen organization. Please add any other details below. Thank you
Submit
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