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)

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*

26, September 2023

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