Consent Form for Participation in AspireAcademy Tutoring Program

Consent Form for Participation in AspireAcademy Tutoring Program
AspireAcademy is a nonprofit organization founded by Kashish Kapoor, dedicated to providing free in-person tutoring services to middle school students in core subjects like Math, English, and Science. Our mission is to empower students by fostering a supportive and collaborative learning environment that helps close the educational gap and inspires a love for learning.
Participation Details:

- Sessions will take place at Herman Intermediate School on Tuesdays or Thrusdays (depending on what group your student is placed in) from 3-4 p.m.

- Students will work with trained high school student tutors (grades 9-12) who are passionate about education and have received training in effective tutoring strategies.

- Activities may include one-on-one and small group instruction, personalized academic support, and engaging educational activities.
VOLUNTARY PARTICIPATION

Participation in this program is entirely voluntary. I may withdraw my child at any time by notifying the program coordinators. AspireAcademy will respect the decision to withdraw without question, and there will be no penalties or negative consequences for choosing to do so. Furthermore, I understand that any information shared during the program, including personal or academic details, will be kept confidential and used solely to enhance the tutoring experience.
Consent and Acknowledgement
1. **Supervision and Safety:** I understand that my child will be supervised by staff and/or volunteers during tutoring sessions. All reasonable precautions will be taken to ensure the safety and well-being of participants.
2. **Medical Emergency:** In the event of an emergency, I authorize AspireAcademy staff to seek necessary medical treatment for my child. I will be responsible for any costs incurred.
3. **Code of Conduct:** I agree that my child will abide by the program’s code of conduct, which includes respectful behavior towards peers and staff. Disruptive behavior may result in removal from the program.
4. **Liability Waiver:** I release AspireAcademy, its staff, and volunteers from any liability for injuries or damages arising from my child’s participation in this program, except in cases of gross negligence.
CONTACT INFORMATION

President: Kashish Kapoor

Email Address: kashishkapoorca@gmail.com

Phone Number: (408-406-9890)
CONSENT

I have read and understood the above information. I consent to my child’s participation in AspireAcademy’s tutoring program under the terms outlined in this form.
Name of Participant

First NameLast Name
Date of Participant Birth

MonthDayYear
Date
Name of Parent/Guardian

First NameLast Name
Date of Acknowledgement

MonthDayYear
Date
Parent/Guardian Contact Number
Please enter a valid phone number.
Parent/Guardian Email Address
example@example.com
**Emergency Contact Details**

Name:blanks
Phone:blank
Signature of Participant

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Signature of Parent/Guardian

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**Photography and Media Release (Optional):** I consent/do not consent (choose one) to the use of photographs or videos of my child taken during program activities for promotional purposes, including social media, newsletters, or website content.

I do consentI do NOT consent
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Consent Form for Participation in AspireAcademy Tutoring Program

Consent and Acknowledgement