Community Learning Center for Children and Youth

Mailing Address
Cleveland State University
2121 Euclid Avenue, JH 130
Cleveland, OH 44115

Campus Location
2485 Euclid Avenue
Julka Hall, Room 130
Cleveland, OH 44115

Phone: 216.687.4768
communitylearningctr@csuohio.edu

OH Perry Tutee Intake Form

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Select up to four choices:

Course Selection:

Student information (please enroll only one student at a time. Complete additional form for each additional child enrolled):

Student Name/Gender/Grade:

2a. Student Gender:

2b. Student Race:

3. Grade:

4. Medium of Regular School Instruction:

5. Disability Status

Parent/Guardian Contact Info (Primary):

6. Preferred Method of Contact/Permission (Primary):

Parent/Guardian Contact Info (Secondary):

10. Preferred Method of Contact/Permission (Secondary):

Student Contact info (usable by student)

16. Devices Available for Use (Select all that Apply):

17. Programs/Applications Used/Approved for Student use during Tutoring:

Mailing Address
Cleveland State University
2121 Euclid Avenue, JH 130
Cleveland, OH 44115

Campus Location
2485 Euclid Avenue
Julka Hall, Room 130
Cleveland, OH 44115

Phone: 216.687.4768
communitylearningctr@csuohio.edu