GROW!

GROW! "Get Ready to Own Wisdom"!

Student Tutoring Application 2023
1st - 5th Grade Mason Students

Sessions: 4:00 - 4:30 PM or 4:45 - 5:15PM

Date: Every Monday (only on full days of school)

November 6, 2023 - March 18, 2024

Location: Mason Community Services
Adults must arrange transportation to Mason Community Services and must pick up each child promptly at the end of the child's session. Our policies do not allow tutors to remain after their session. If your child is not picked up immediately after their session three times throughout the school year, he/she/they will not be allowed to continue attending. Thank you for understanding.
In compliance with the Federal Family Education Rights and Privacy Act (FERPA), I authorize Mason Community Services, Inc. to receive educational information from my child's teacher for the purpose of assisting my child's educational needs.
"FERPA" Signature*

Clear
Child's Name*
Date of Birth:*
Address*
Street and City
School*
Teacher*
Grade*
Child's Allergies*
Peanuts, chocolate, etc.
Family email*
example@example.com
Home Phone*
Parent/Guardian work/cell phone*
EMERGENCY CONTACTS
Contact #1
Relationship
Phone
Contact #2
Relationship
Phone
PERMISSION FOR PICK UP

In addition to those listed above, the following people are allowed to pick up my child:
Name #1*
Relationship*
Phone*
Name #2
Relationship
Phone
PARENT/GUARDIAN SIGNATURE
Signature*

Clear
Date*

MonthDayYear
Date
Name*
Parent/Legal Guardian Name
Photography and Video Release (optional) Mason Community Services may, from time to time, document the activities of our tutoring program, GROW, with photos or videos. I hereby assign and grant to Mason Community Services, Inc. and assign the unqualified right to the ownership, proceeds and use of all photographs or video of me or my child without reservation or limitation, including use of photographs or video of me or my child for, but not limited to, advertising, educational and promotional purposes.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

GROW! "Get Ready to Own Wisdom"!

EMERGENCY CONTACTS

PERMISSION FOR PICK UP

PARENT/GUARDIAN SIGNATURE