Spring 2023 Tutoring Registration Form

Spring 2023 Tutoring Registration Form
Student Information
Are you approved for the Ohio Ace?

YesNo
Student's Name*

First NameLast Name
Grade (22/23 yr)*

Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade
Area of Focus

Math and ReadingReadingMath
Days and Times for Tutoring Sessions (Tuesdays and Thursdays Only)*

4:30 PM-5:30 PM5:30 PM - 6:30 PM
School Name *
School Type*

PublicPrivateCharter
Skip to parent/guardian information if you are not registering a sibling.
Sibling's Name Attending (optional)

First NameLast Name
Grade Entering (sibling)

Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade
Area of Focus (sibling)

Math and ReadingReadingMath
Days and Times for Tutoring Sessions (Tuesdays and Thursdays Only)

4:30 PM-5:30 PM5:30 PM - 6:30 PM
School Name
School Type

PublicPrivateCharter
Parent/Guardian Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information

Other than the name listed above!
Emergency Contact's Name*

First NameLast Name
Relationship *
Phone Number*

Area CodePhone Number
COVID-19

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.I further acknowledge that Fail Me Not Tutoring LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that Fail Me Not Tutoring can not guarantee that I/my child will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families. I voluntarily seek services provided by Fail Me Not Tutoring LLC and acknowledge that I am increasing my/ my child’s risk of exposure to the Coronavirus/COVID-19. I acknowledge that I/my child must comply with all set procedures to reduce the spread while attending my appointment.
Do you agree to the COVID-19 Guidelines*

AgreeDisagree
Informed Consent and Acknowledgement
I hereby give my approval for my child’s participation in any and all activities prepared by Fail Me Not Tutoring, LLC during the selected semester.
*

AgreeDisagree
Media Disclosure
Fail Me Not Tutoring, LLC may periodically photograph students participating and working during tutoring sessions. These photos may be used in a variety of ways; public relations and marketing purposes: images printed on brochures, posters, and newsletters or on our Facebook and Instagram pages. Full names will not be included in photographs or social media sites. We appreciate your support and look forward to showcasing the work our scholars are doing during their tutoring sessions.
*

AgreeDisagree
Price
Registration Fee: $75/pp

Fall Tutoring: $265/mo

*Registration Fee is the only thing due today.
Confirmation
BY ACKNOLWDING AND SIGNING BELOW, I AM AKNOWLEDGING AND AGREEING TO THE POLICY AND PROCEDURES LISTED ON OUR REGISTRATION PAGE OF OUR WEBSITE, AS WILL AS THE REGISTRATION FORM.
Signature

Clear

My Products*

Registration Fee/Student

$75.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Spring 2023 Tutoring Registration Form

Student Information

Parent/Guardian Information

Emergency Information

COVID-19

Informed Consent and Acknowledgement

Media Disclosure

Price

Confirmation