Dear Reading Soul Mates Tutor:

We are delighted that you are volunteering with us to help struggling students improve their literacy skills. This is an effort that we believe benefits our entire community. It is our policy and a Gaston County Schools policy to secure a criminal background check on all volunteers before placing them with a student. Please provide your personal information in the spaces found below.

In addition, one way we share Reading Soul Mates with the community is by publishing photographs, direct quotes, and other written material via media, agency newsletters, flyers, and other publications. Should we have the opportunity to share your experience in printed form or photograph, we will need your permission. Please note that by signing, you are granting permission, ad perpetuum, to the Gaston Literacy Council, Inc., for the purposes above. You may revoke your permission at any time by submitting a written request to Gaston Literacy Council, Inc.

Should you have questions, please contact Gaston Literacy Council, Inc. at 704-868-4815 or via email at a.anthony@gastonliteracy.org or m.deely@gastonliteracy.org.

Your truly,

Merry Deely
Reading Soul Mates Coordinator
Gaston Literacy Council, Inc.

Annie Anthony
Reading Soul Mates Coordinator
Gaston Literacy Council, Inc.

Full Name (including maiden/married name)*
Home Mailing Address*
Street Address City State ZIP Code
Phone
Email
Preferred time/day to tutor (ie: Tuesdays 9-10:00)*
Preferred method(s) of communication*
- Telephone
- Text
- Email
Date of birth (mm/dd/yyyy)*
Consent*
I agree to the Media Release
I authorize Gaston Literacy Council, Inc. to use my quotes and/or photographs while participating in the Reading Soul Mates program. I understand the quotes and/or photographs may be published by Gaston Literacy Council, Inc., Gaston County Schools publications and/or other local news sources.