STUDENT TUTORING

REGISTRATION FORM

Step 1

English
Spanish

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Student Lives With

Name of Mother or Guardian

Name of Father or Guardian

Name of Guardian

Step 2

English
Spanish

LOCAL EMERGENCY CONTACT(S)

Doy permiso para que el personal de JIM Enterprises se comunique con la asistencia médica necesaria en caso de emergencia. El personal de JIM Enterprises se pondrá en contacto con el mencionado anteriormente inmediatamente. Si mi hijo se enferma o lesiona durante la tutoría, acepto recuperar mi niño tan pronto como sea posible.

MEDICAL CONDITION(S) / ALLERGIES

Does Your Student Have Any Medical Condition(s) Or Allergies?

If Yes, Please Explain.

Step 3

English
Spanish

AFTER TUTORING

My student will be picked up from tutoring by someone on this form (Parent, Guardian and/or Emergency Contact).*

My student will return to the school provided After School Program.*

My student will take the bus home.*

My student will walk home from tutoring. I release all liability from JIM Enterprises.*

If other, please explain.

PHOTO RELEASE AUTHORIZATION

I give permission for my student’s photo to be taken for promotional materials.*

ADDITIONAL STUDENT INFORMATION

Please provide any additional information that would help us provide your student with the best support.

Signature of Parent/Guardian *
Date*

30, September 2022

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