Preschool Literacy Boost

Preschool Literacy Boost
Grace College

Center for Literacy and Learning

Mount Memorial, 3rd Floor

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Sessions will be held on Mondays and Wednesdays starting Monday, January 26th and ending Wednesday, April 1st.

Session time:

1:00pm - 2:30pm

Center for Literacy and Learning Registration Form

We're thrilled to have the opportunity to work with your child at The Center for Literacy and Learning at Grace College. Please provide the following information so that we can enroll your child and initiate the process of arranging tutoring services.

Student Personal Information
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Address*

Street Address

CityState / Province

Postal / Zip Code
Primary Parent Phone*

Area CodePhone Number
Primary Parent Email*
example@example.com
Allergies (food or other) that the center should be aware of

Photo Release

I give permission for my child and/or myself/my family to appear in photographs and/or video recordings for any lawful purpose made during tutoring. This permission also extends to the editing and use of those photographs and/or video recordings for tutoring publications, promotion, advertising, and presentations.
Student Photo Submission*

YesNo
Student name (printed) *
Parent Signature*

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Date*

MonthDayYear
Date

Tutoring Center Liability Waiver and Release Form
Student name*
In consideration of being allowed to participate in the tutoring services provided by The Center for Literacy and Learning located at 1 Lancer Way, the undersigned hereby agrees as follows:

Assumption of Risk: I understand that tutoring activities may involve certain risks, including but not limited to temporary emotional distress. I voluntarily assume all such risks associated with my participation and waive any claims against The Center for Literacy and Learning, its owners, employees, or agents for any distress, loss, injury, or damage arising from my/my student's participation.

Medical Treatment: In the event of any medical emergency, I authorize The Center of Literacy and Learning staff to seek medical treatment for myself/my child, and I agree to be financially responsible for any costs incurred as a result of such treatment.

Responsibility for Personal Property: I understand that The Center for Literacy and Learning is not responsible for any loss or damage to personal property brought onto the premises by myself/my child.

Legal Guardianship: I certify that I am the parent or legal guardian of the minor and have the authority to make decisions on their behalf.

I have read this Liability Waiver and Release Form in its entirety and fully understand its terms. I acknowledge that by signing this form, I am waiving certain legal rights, including the right to sue. I agree to be bound by its terms.
Signature*

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Date*

MonthDayYear
Date

Authorized Pick-Up and Emergency Contact Information
Student name*
Authorized Pick-Up List:

The following individuals are authorized to pick up the participant in the event of an emergency or at the conclusion of the program/activity:
Name*

First NameLast Name
Relationship to student*
Name

First NameLast Name
Relationship to student
Identification Requirements: Authorized individuals must present a valid form of identification (e.g., driver's license, state ID) when picking up the participant. Failure to provide proper identification may result in denial of pick-up privileges.
Emergency Contact Information:
Name*

First NameLast Name
Relationship to student*
Phone Number*

Area CodePhone Number
Name

First NameLast Name
Relationship to student
Phone Number

Area CodePhone Number
Signature*

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Date*

MonthDayYear
Date

Purchaser First Name*
Purchaser Last Name*
Email*
example@example.com
Choose session*

10:00am - 11:00am1:00pm - 2:00pm

Payment*

Preschool Tutoring$200.00

Enter coupon

Total $0.00

Credit Card

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