Child's Name
*
Child's Age/Birthday
*
Child's Grade
*
Address
*
Mother's/Guardian's Name
*
Father's/Guardian's Name
*
Home Phone (Mother)
*
Work Phone(Mother)
*
Cell Phone(Mother)
*
Mother's/ Guardian's Email Address
*
Home Phone(Father)
*
Work Phone(Father)
*
Cell Phone(Father)
*
Father's/Guardian's Email Address
*
Emergency Contact Person #1 Name and Phone Number
*
Emergency Contact Person #2 Name and Phone Number
*
Child's Doctor Name and Phone Number
*
Does your child have any known allergies? If yes, please list.
*
Are you concerned that your child may be prone to any type of allergies? Describe
*
Does your child have any medical conditions in which we should be made aware of?
*
Constipation
Convulsions
Diarrhea
Fainting Spells
Frequent Colds
Stomach Upsets
Frequent Sore Throats
Asthma
Ringworm
Skin Rash
Nose Bleeds
Other
None
Does your child have any speech, hearing or visual problems?
*
Would there be any restrictions to play or activities?
*
Are there any food allergies or restrictions?
*
What is your child's favorite food?
*
What food does your child dislike?
*
Are there any siblings that attend this school? Please name them and specify ages and gender.
*
What language(s) are spoken at home?
*
Does your child receive special education services?
*
I give All 4 One Tutoring consent that photos/video of my child involved in activities can be taken for use for newsletter and/or social media post (Facebook/Instagram only). I understand that if my child's image is used, only his/her first name will be used.
*
Yes I give All 4 One Tutoring permission to use my child's image for newsletters and social media post (Facebook/Instagram only).
No, I do not give All 4 One Tutoring permission to use my child's image for newsletters and social media post (Facebook/Instagram only)
I only give All 4 One Tutoring permission to use my child's image in newsletters.
I only give All 4 One Tutoring to use my child's image for social media post (Facebook/Instagram only)
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