Reading Clinic Application Form

Tutoring occurs each fall and spring semester.

To prevent the transmission of COVID19 from people without symptoms, the Centers for Disease Control and Prevention (CDC) has recommended that everyone wear a cloth face mask, such as a homemade face mask. By checking this box I verify that I have read and understand that my child may be required to wear a face mask during his/her tutoring session.

Please fill in all the blanks on this form

Child's Name:

Current Grade Placement:

School Child Attends:

Child's Date of Birth:

Parent's or Guardian's Full Name:

Mailing Address:

City:

State:

Zip Code:

Parent's E-mail:

Home Phone:

Cell Phone:

Has your child ever attended our program? Yes No

If yes, when?

Do you think your child is reading above grade levelat grade level, orbelow grade level?

Explain, as thoroughly as you can, your concerns about your child's reading skills:

Your child, with their tutor, may be photographed while in the reading clinic. These pictures may be shown to diverse groups such as: the Board of Regents, accreditation teams, and other students for the purpose of showing our undergraduates working with children in the Northern State University Reading Clinic. At no time will your child be identified by name; however, I must make you aware of these photographs.

Yes, I approve of you taking my child's photograph.
No, I do not approve of you taking my child's photograph.

Scheduled Times - You will be sent a letter of acceptance prior to the start date.
All times are Central Standard Time (CST).

Select a Term:

Monday & Wednesday 3:30 p.m. - 4:15 p.m.
3:45 p.m. - 4:30 p.m.
4.00 p.m. - 4:45 p.m.
4.15 p.m. - 5:00 p.m.

Tuesday & Thursday 3:30 p.m. - 4:15 p.m.
3:45 p.m. - 4:30 p.m.
4.00 p.m. - 4:45 p.m.
4.15 p.m. - 5:00 p.m.

NSU Reading Clinic is non-profit. At present, the clinic operates primarily with tuition fees paid; therefore, we ask that you pay $80.00 for the tutoring sessions on the first day of tutoring. Please make checks payable to the NSU Reading Clinic.