TUTOR FORM

Bellows Free Academy

ALTERNATIVE CURRICULUM / TUTOR FORM School Year: _________________

First Semester: ________ Second Semester: ________ (Please check one)

Student Name: ___________________________________

ID #: ____________________ Yes

Course #: ___________

Course Name: _____________________ Modified Curriculum No

Meeting Time Period: __________

Room #: __________

Potential Credit to be Awarded: ______________

______________________________________________________________________________ PowerSchool Teacher’s Name (Print) Signature Date

______________________________________________________________________________ Case Manager’s Name (Print) Signature Date

______________________________________________________________________________ Team Leader’s Name (Print) Signature Date

Heather Dunigan

______________________________________________________________________________ (Print) Signature Date

Please circle counselor:

Judy

Stephanie

Chris

Amy

Preston