MEP Tutoring Services

Registration Form
Child's Name:

First NameLast Name
Birth Date:

MonthDayYear
Age:
School District and School:
Grade:
Does your child receive free/reduced lunch?

Parent/Guardian:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
E-mail:

Emergency Contact 1:

First NameLast Name
Emergency Contact 1 Phone Number:

Area CodePhone Number
Emergency Contact 2:

First NameLast Name
Emergency Contact 2 Phone Number:

Area CodePhone Number
Authorized Pick-up Person 1:

First NameLast Name
Authorized Pick-up Person 2:

First NameLast Name
Program Information
Program Days and Times:
Medical Information
Allergies and Reactions:
Medical Conditions/Concerns:
Current Medication(s) Does the student carry an EpiPen, inhaler or daily medication? Please type "yes" and list medication(s) or type "no" and move to the next question.
Doctor Contacts
Primary Care Physician:

First NameLast Name
Phone Number:

Area CodePhone Number
Preferred Hospital/Clinic:
Insurance Information
Policy Holder Name:
Insurance Company:
Policy/Group Number:

Area(s) of Concern:
How did you hear about us?
Mentoring Information
Student Interests/Hobbies:
Goals Student Hopes to Achieve:
Tutoring Information
Academic Strengths:
Area(s) in Need of Improvement:
Hold Harmless, Release of Liability, and Indemnification Agreement

Making Excellence Possible, Inc. (MEP)
Purpose

Making Excellence Possible, Inc. (MEP) is committed to providing a safe, supportive, and enriching tutoring and/or mentoring environment for all participants. While every reasonable effort is made to ensure the safety and well-being of each student, participation in MEP programs involves certain inherent risks.

Assumption of Risk

I understand that my child will participate in educational and related activities sponsored by Making Excellence Possible, Inc. (MEP). I voluntarily allow my child to participate and acknowledge that participation may involve risks that cannot always be eliminated despite reasonable precautions.

Release and Hold Harmless

In consideration of my child’s participation in the Making Excellence Possible, Inc. (MEP) tutoring and/or mentoring program, I, on behalf of myself, my child, my heirs, successors, and assigns, hereby release, waive, discharge, and agree to hold harmless Making Excellence Possible, Inc. (MEP), its Board of Directors, officers, employees, tutors, mentors, volunteers, contractors, partnering organizations, facilities, sponsors, and representatives from any and all claims, demands, causes of action, damages, liabilities, losses, costs, or expenses arising from or related to my child’s participation in the program, except where such injury or loss results directly from gross negligence or willful misconduct.

Medical Authorization

In the event of a medical emergency, I authorize the personnel of Making Excellence Possible, Inc. (MEP) to obtain professional emergency medical treatment for my child if I cannot be reached. I accept full financial responsibility for any medical or related costs incurred.

Making Excellence Possible, Inc. (MEP) and the staff are not liable for pre-existing conditions or injuries if the listed procedures are followed.

Personal Property

I understand that MEP is not responsible for lost, stolen, or damaged personal property brought to the program, including electronic devices, money, clothing, jewelry, or other valuables.

Transportation

I understand that unless specifically provided by MEP through a written authorized transportation arrangement, I am responsible for the transportation of my child to and from the program. I agree to follow all pickup and dismissal procedures established by MEP.

Behavioral Responsibility

I understand that my child is expected to follow all program rules and adhere to the behavioral expectations. Failure to comply may result in disciplinary action, including suspension or dismissal from the program.

Indemnification

I agree to indemnify and defend Making Excellence Possible, Inc. against any claims or legal actions resulting from my child’s intentional misconduct or violation of program rules while participating in MEP activities.

Acknowledgment

By signing below, I acknowledge that:

● I have read this Hold Harmless, Release of Liability, and Indemnification Agreement.

● I fully understand its contents.

● I understand that I am giving up certain legal rights by signing this agreement.

● I voluntarily agree to all terms and conditions.
Program Year:
Parent/Guardian:

First NameLast Name
Student:

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Photo, Video, and Media Release:

I grant MEP permission to photograph, video record, and use my child's likeness for educational, promotional, fundraising, website, and social media purposes without compensation.

I understand names will not be published with images unless separately authorized.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Technology & Internet Acceptable Use:

Technology is for educational purposes only.

No cyberbullying, inappropriate content, hacking, password sharing, or unauthorized downloads.

Users should protect privacy and report concerns immediately.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent Code of Conduct:

Treat staff, students, volunteers, and families respectfully.

Support program expectations, communicate professionally, and avoid disruptive behavior.

Repeated violations may result in termination of participation.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Late Pickup Policy Acknowledgment:

Parents must pick students up on time.

Repeated late pickups may result in fees and/or program dismissal.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Consent:

I give permission for my child to participate in MEP tutoring, mentoring, enrichment, and/or approved program activities.

I certify that the emergency contact and medical information provided is accurate.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Date:

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

Registration Form

Hold Harmless, Release of Liability, and Indemnification Agreement