You must have JavaScript enabled to use this form. 1 Start 2 Complete Please complete this form on the final business day of the month. Please allow 7-10 business days for the payment to process. Personal Information 1. Name * 2. Phone Number * 3. Email * 4. Did you work as a tutor for the Community Learning Center during Fall 2022? * Yes No Hours Record 5. Please select the month you are entering your hours for: * January February March April May June July August September October November December 6. For Week 1 of selected month, please indicate how many days you worked on site: * 1 Day 2 Days 3 Days 4 Days 5 Days None Date Selection (1 Day) What day during this week did you work? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (2 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (3 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (4 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (5 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fifth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM 6a. How many total hours did you work for week 1? * If you did not work any hours this week, please type "N/A". 7. For Week 2 of selected month, please indicate how many days you worked on site: * 1 Day 2 Days 3 Days 4 Days 5 Days None Date Selection (1 Day) What day during this week did you work? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (2 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (3 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (4 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (5 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fifth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM 7a. How many total hours did you work for week 2? * If you did not work any hours this week, please type "N/A". 8. For Week 3 of selected month, please indicate how many days you worked on site: * 1 Day 2 Days 3 Days 4 Days 5 Days None Date Selection (1 Day) What day during this week did you work? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (2 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (3 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (4 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (5 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fifth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM 8a. How many total hours did you work for week 3? * If you did not work any hours this week, please type "N/A". 9. For Week 4 of selected month, please indicate how many days you worked on site: * 1 Day 2 Days 3 Days 4 Days 5 Days None Date Selection (1 Day) What day during this week did you work? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (2 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (3 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (4 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Date Selection (5 Days) Select the first date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the second date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the third date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fourth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM Select the fifth date you worked: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Select the timeframe you worked: 2-2:30PM 2:30-3PM 3-3:30PM 3:30-4PM 4-4:30PM 4:30-5PM 5-5:30PM 5:30-6PM 9a. How many total hours did you work for week 4? * If you did not work any hours this week, please type "N/A". 10. Write your total hours for Weeks 1-5: * 11. Did you incur an out of pocket background check expense during this calendar month? * Yes No If yes, please write the total cost you incurred: 12. During this reported calendar month, did you fuly attend the following (check all that apply): * Tutoring 101 and Homework Help Online Training (1 hour) Basic and Intensive Reading Support (1.5 hours) Basic and Intensive Math Support (1.5 hours) I have not attended any of these trainings. Other... 12. During this reported calendar month, did you fuly attend the following (check all that apply): Other... ** Each training's associated quiz must be submitted to verify completion of training module(s). Leave this field blank