Tutoring Registration Form

Tutoring Registration Form Multi

Learning Zone 2024-2025
Student 1

First NameLast Name
Student 2

First NameLast Name
Student 3

First NameLast Name
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Individuals Authorized to Pick up Student

Anyone picking up a student after tutoring will be asked to show a photo ID. Only individuals authorized in writing by the parent/guardian will be permitted to pick up student.
1. Name

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.
2. Name

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Student 1 Information
Grade Level 2024/2025
Birth Date
School
Teacher's Name
Identify Areas of Learning Needs

ReadingLanguageMathOther
Please identify any learning disabilities, behavior disorders, special school programs, allergies, etc.
Student 2 Information
Grade Level 2024/2025
Birth Date
School
Teacher's Name
Identify Areas of Learning Needs

ReadingLanguageMathOther
Please identify any learning disabilities, behavior disorders, special school programs, allergies, etc.
Student 3 Information
Grade Level 2024/2025
Birth Date
School
Teacher's Name
Identify Areas of Learning Needs

ReadingLanguageMathOther
Please identify any learning disabilities, behavior disorders, special school programs, allergies, etc.
Photography Permission
I hereby give permission to FPC Learning Zone to take photos of my son(s)/daughter(s): student 1 name, student 2 name, student 3 name. For the sole purpose of promoting the program within the classrooms, church’s monthly newsletter, church website, and tutoring brochures.
Photography Permission*

YesNo
Signature*

Clear
Date

MonthDayYear
Date
Medical Form

2024-2025
Health Insurance Company
Policy Number
Group Number
Phone Number
Please enter a valid phone number.
Emergency Contact Information

In an emergency, please notify one of the following:
1. Name

First NameLast Name
Relationship to Minor
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
2. Name

First NameLast Name
Relationship to Minor
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Medical History

Student #1
Has minor 1 had all school-required vaccinations?

YesNo
Date of last Tetanus Shot:
Does minor 1 have a communicable disease or medial condition that may be a risk to others?

YesNo
Please List any Food related allergies:
Please list the name, dosage, and purpose of medications currently being taken by Minor 1:
Please describe any special considerations regarding Minor (medical conditions, food allergies, dietary restrictions, activity limitations, behavioral issues/concerns, etc):
Medical History

Student #2
Has minor 2 had all school-required vaccinations?

YesNo
Date of last Tetanus Shot:
Does minor 2 have a communicable disease or medial condition that may be a risk to others?

YesNo
Please List any Food related allergies:
Please list the name, dosage, and purpose of medications currently being taken by Minor 2:
Please describe any special considerations regarding Minor (medical conditions, food allergies, dietary restrictions, activity limitations, behavioral issues/concerns, etc):
Medical History

Student #3
Has minor 3 had all school-required vaccinations?

YesNo
Date of last Tetanus Shot:
Does minor 3 have a communicable disease or medial condition that may be a risk to others?

YesNo
Please List any Food related allergies:
Please list the name, dosage, and purpose of medications currently being taken by Minor 3:
Please describe any special considerations regarding Minor 3 (medical conditions, food allergies, dietary restrictions, activity limitations, behavioral issues/concerns, etc):
Authorization for Medical Treatment

Note: Each person who has legal custody of Minor should sign this Authorization for Medical Treatment, and only a person who signs will be considered a legal custodian of Minor.
As the parent or legal guardian of Student 1 name, student 2, Student 3 each of the undersigned gives his or her authorization and consent for the First Presbyterian Church of Turlock, CA and the Church’s adult employees, agents, and volunteers (collectively with the Church, the “First Presbyterian Church of Turlock Parties”) to seek, authorize, and consent to such medical or dental care for Minor (“Treatment”) as any one or more of them may deem necessary or appropriate. Such Treatment (1) shall be provided upon the advice of and supervision by a physician, surgeon, dentist, or other medical practitioner licensed to practice under the laws of the state or jurisdiction in which such Treatment is sought, and (2) may include, without limitation, X-ray examination; anesthetic; medical, dental, or surgical diagnosis or treatment; and hospital care. Every effort will be made to contact one of the signers of this authorization before treatment is authorized whenever possible. This Authorization for Medical Treatment may be photocopy hereof shall be as valid as an original copy.
Each of the undersigned acknowledges and agrees that the First Presbyterian Church of Turlock Parties shall not be legally or financially liable for any bill or expense incurred in, or any cause of action or claim arising from, the provision of any Treatment or the failure to provide or seek any Treatment. In consideration of Minor’s participation in one or more events sponsored by the Church, each of the undersigned hereby agrees to indemnify, defend, and hold harmless the First Presbyterian Church of Turlock Parties from and against any and all losses, damages, liabilities, or expenses (including, without limitation, reasonable attorneys’ fees and other costs of defense) in connection with any and all actions, suits, claims, or demands that may be brought or instituted against any First Presbyterian Church of Turlock Party and arise out of or result from the provision of any Treatment or the failure to provide or seek any Treatment. This paragraph shall survive any termination or expiration of the Authorization for Medical Treatment for any reason.
Signature*

Clear
Name*

First NameLast Name
Date

MonthDayYear
Date
Second Parent/Guardian Signature

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
Consent and Discharge of Liability

PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING IT. IT AFFECTS THE LEGAL RIGHTS OF YOU, THE STUDENT, AND OTHERS.
I, the undersigned parent/legal guardian of student 1 name, student 2, student 3 hereby give my permission for the student(s) to participate in any program or event occurring from July 1st 2024 through July 30th 2025, and to be transported by an employee, agent, or volunteer (an “Agent”) of the First Presbyterian Church of Turlock, CA in case of an emergency.
In consideration of the student being allowed to participate in the Program:
I understand that the church and its volunteers will exercise their judgment in supervising the student and other participants in all sponsored activities and have a right to expect conduct of activities to be accomplished in a safe and careful manner. In spite of this care, it is always possible for the student to be injured or become ill during the activities. In consideration of sponsoring, organizing and supervising the activities during this time period as well as providing other services before, during and after the activities, I agree to defend, and hold harmless the Church and any of its Agents, employees or volunteers (collectively, the “First Presbyterian Church of Turlock Parties”) from and against any and all losses, damages, liabilities, or expenses that arise out of or result from the Student participating in the Program.
I understand and agree that the Student may be sent home at my expense if any Agent, employee or volunteer determines that the Student has: engaged in disruptive behavior, broken any rules or constitutes a threat to the safety or well being of any other participant at any time during any activity
Signature*

Clear
Name*

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Tutoring Registration Form Multi

Individuals Authorized to Pick up Student

Student 1 Information

Student 2 Information

Student 3 Information

Photography Permission

Medical Form

Emergency Contact Information

Medical History

Medical History

Medical History

Authorization for Medical Treatment

Consent and Discharge of Liability