Student Registration Form

Student Registration Form

by KLEVER TUTORING
Information
Student's Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
CLASS NUMBER Ex. 2-202
School number Ex. Ps69
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred Program*

HOMEWORK CLUB K-7 MONTHLY MEMBERSHIP $425HOMEWORK CLUB K-7 MONTHLY 3 TIMES A WEEK MEMBERSHIP $375HOMEWORK CLUB DAILY $40PRIVATE TUTORING SESSIONSNY STATE TEST PREP GROUP TUTORING
Parent/Guardian Information (Mother)
Name*

First NameLast Name
Home Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
Parent/Guardian Information (Father)
Name*

First NameLast Name
Cell Number*

Area CodePhone Number
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Names of other responsible adults who are authorized to pick-up child from Klever Tutoring, INC. and can be contacted if a parent/guardian cannot be reached.Nombre de dos adultos responsables que están autorizado para recoger al niño/a en Klever Tutoring, INC. y que puedan ser contactados si un padre/guardián no puede ser localizado:
NAME AND PHONE NUMBER
Our main priority is to keep our students safe, the authorized adult(s) will need to show ID on the time of pick-up.

Nuestra prioridad principal es mantener a su hijo/a seguro/a, el/los adultos/s autorizado/s necesitara/n ensenar ID a la hora de recoger al estudiante.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty: