Every Student Summer Sessions

Last Name*

First Name*

School*

Birth Date*

MonthDayYear

ENTERING grade for 2024-2025 school year*

Address*

City*

State*

Zip*

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Emergency Contact Relationship*

Parent/Legal Guardian*

Relation*

Phone Number*

Area CodePhone Number

Email*

example@example.com

Parent /Legal Guardian 2

Relation 2

Phone Number 2

Area CodePhone Number

Email 2

example@example.com

All fields are required below. If nothing applies, please put "NONE" in the box.

Any physical, mental or other condition that would require special attention or medication? (If applicable, please list the medications. Except for EpiPens (which require a separate form, please request), staff do not administer medicine.*

Any learning differences that we should be aware of?*

Any allergies? (Please note: no food is served at sessions)*

Please select ALL the dates you would like your child to attend (Sessions are first come, first serve; based on staff availability; confirmations will be sent out mid-June)

Describe your student ACADEMICALLY!

Where are they in terms of their learning? What are they learning in school? Would you describe them as accelerated, struggling, or somewhere in between? How fast does your student pick up concepts? Are there specific concepts you would like us to work on?

Describe your student PERSONALLY!

How would you describe their personality? Are they more quiet or outgoing? What are some of their hobbies? (Anything that would help us get to know your child better!)

Any additional information?

Is your student an English Language Learner?*

YesNo

Are you registering your student to be a Teacher's Assistant? (MUST BE entering 7th grade or older)*

YesNo

Authorized Pick up (Who is authorized to pick up your child from the session? Please list their names and contact info)

My signature on this form and my child's participation in Every Student Summer Sessions via Every Student Tutoring Program, in consideration of such participation, I hereby waive, release, and discharge any and all claims against Every Student Tutoring Program and its members for accidental injury, property damage, illness, or death occurring during or by reason of participating in said tutoring. I shall immediately indemnify, defend, protect, save, and hold harmless Every Student Tutoring Program and its members, from and against all damages of whatever nature arising out of participation in this tutoring. I shall assume the full costs of any judgment, settlement, and defense of any suits or other legal proceedings instituted against Every Student Tutoring Program and its members for accidental injury, property damage, illness, or death occurring during or by reason of my child’s participation in this tutoring, including legal expenses and attorney fees of whatever nature arising out of his/her participation in this activity.

I grant permission to Every Student Tutoring Program and its members the irrevocable and unrestricted right to produce photographs and video taken of my child while at Every Student Summer Sessions for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by Every Student Tutoring Program. I hereby release Every Student Tutoring Program and its legal representatives from any and all liability for any violation or claims relating to said images or video.

By signing below, I acknowledge and confirm that I am the parent or legal guardian of the above named student, and am over the age of 18. I certify that my child has my permission to attend this program and participate in all activities. I also confirm that I have read, understand, and agree to the terms stated herein above.

Signature*

Please verify that you are human*

Every Student Summer Sessions - Student Registration

Student Name

Student Information

Parent or Legal Guardian Information

Health

Scheduling

Preferences

Student Release