Family Camp

Road to Learning Application

Progress on this form cannot be saved, please plan on completing all at once.
Applicant's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Applicant's School*
Mother/Guardian*

First NameLast Name
Father/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Mom's Cell Number*

Area CodePhone Number
Dad's Cell Number*

Area CodePhone Number
Mom's Email*
Dad's Email*
Authorized to Pick Up Child
Phone Number

Area CodePhone Number
List Any Medications Child is Taking
List Any Testing or Diagnosing Completed (current IEP, etc)

Fee Schedule
Registration Fee: $75.00 Tutoring Fee: $52.00/hour
4 Weeks Prepaid Plus Registration Fee: $491.00

Each tutoring session is one hour and is provided by a Barton trained tutor in a one-on-one setting. A minimum of two hours per week is required. Tutoring can be scheduled at any time between 8:00 am and 6:00 pm Monday through Thursday. We have limited availability on Fridays.
- 1 month prepaid required
- $5 late fee for accounts three weeks overdue
- $20 service fee for each returned check (RTL reserves right to refuse any future checks)
Please list your tutoring preferences:
Select 1st Choice*
1st Choice Time*

:HourMinutesAM/PM Option
Select 2nd Choice*
2nd Choice Time*

:HourMinutesAM/PM Option
Select 3rd Choice*
3rd Choice Time*

:HourMinutesAM/PM Option
We will assign your schedule based on your preferences and in accordance with our availability. You will receive a letter verifying your tutoring days and times.

Your tutoring sessions are standing appointments.

RTL strives to keep our program at a high level of excellence. This requires a serious commitment from the students and the tutors. Consistency in attendance is a primary factor in achieving educational growth. Parents are invited to attend the tutoring sessions in an "in the background" listening mode. Siblings of the student or other children are not to be brought into the tutoring sessions. There is a $5.00 late pickup charge for each 15 minute period after the scheduled tutoring time.

Following is a list of the holidays in which RTL is closed and there is no tutoring:

New Year's Eve
New Year's Day
Martin Luther King Day
President's Day
Good Friday
Spring Break (1 week)
Memorial Day
Independence Day
Labor Day
Columbus Day
Veteran's Day
Thanksgiving (Wed.-Fri.)
Christmas Break (2 weeks)

We follow the Lake Zurich School District #95 calendar for holiday dates that occur during the school year. Summer holidays follow the national calendar. If a holiday is during the weekend, the day observed will be selected at RTL's discretion. You will receive a full tuition credit for any holiday that RTL is closed or any tutor cancellation.

On days other than the holidays listed above, RTL is open for business. If advance notice is given, any vacation or absences will be credited on your account at one half of the tuition rate. Your payment of half of the tuition holds your tutoring time, as well as covers overhead and the tutor's salary. If no advance notice is given of cancellation or vacation, no tuition will be credited. Excessive cancellations or no-shows will result in termination of services. If you plan to discontinue services, please provide two weeks written notice for your student's final review and exit assessment.

Notify us of absences at: 847-307-0073

Medical Release & Waiver
Applicant's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Mother/Guardian*

First NameLast Name
Father/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Mom's Cell Number*

Area CodePhone Number
Dad's Cell Number*

Area CodePhone Number
Mom's Email*
Dad's Email*
Authorized to Pick Up Child
Phone Number

Area CodePhone Number
Your signatures on this page creates a binding contract between the student (or the Guardian for the student) and Road to Learning, a division of Quentin Road Christian School and all Quentin Road Church Divisions.

MEDICAL RELEASE:

AUTHORIZATION: In case of a medical emergency, I understand that my child will be transported to the hospital by the local emergency unit for treatment if the local emergency resource (police, rescue squad, etc.) deems it necessary. My child will be transported at the expense of the parents/guardians. It is understood that in some medical situations the staff will need to contact the local emergency resource before the parent, my child's physician, and/or other adult acting in my behalf. I hereby give permission to ROAD TO LEARNING at QUENTIN ROAD CHRISTIAN SCHOOL to take any emergency measures (first aid, disaster, etc.) that are deemed necessary for the protection and care of my child while under the supervision of the school.

WAIVER, RELEASE AND INDEMNIFICATION:

Acknowledgment of Risks of Injury: "As a participant in Road to Learning, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries including death, damages or loss which my child, or my family may sustain as a result of participating in any and all activities connected with or associated with such programs."

Waiver of Claim for Injury: "I agree to waive and relinquish all claims I may have as a result of participating in the programs against the Quentin Road Bible Baptist Church, Christian School, Road to Learning, and Preschool and its employees."

Release from Liability: "I do hereby fully release and discharge the Quentin Road Bible Baptist Church, Christian School, Road to Learning, and Preschool, its employees and/or agents from any and all claims from injuries, including death, damages or loss which may accrue to me on account of my participation in these programs."

Indemnity and Defense: "I further agree to indemnify and hold harmless and defend the Quentin Road Bible Baptist Church, Christian School, Road to Learning and Preschool and its employees from any and all claims resulting from injuries, including death, damages and losses sustained by me and arising out of, connected with, or in any way associated with the activities of the programs."

This waiver, release and indemnification of all claims is executed by the undersigned in consideration of Quentin Road Bible Baptist Church, Quentin Road Christian School, Road to Learning, and Quentin Road Christian Preschool allowing my child to participate in all the program activities and other good and valuable consideration, sufficiency of which is hereby acknowledged.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE WAIVER AND RELEASE OF ALL CLAIMS AND INTEND TO BE LEGALLY BOUND BY SAME.
Check to Agree*

I Agree
Please click here to read our handbook of policies.
I have read and agree to the entire handbook of policies.*

I Agree
BOTH PARENT/GUARDIAN SIGNATURES REQUIRED
Mother/Guardian*

First NameLast Name
Father/Guardian*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Road to Learning Application

Fee Schedule

Please list your tutoring preferences:

Your tutoring sessions are standing appointments.

Medical Release & Waiver

MEDICAL RELEASE:

I HAVE READ AND FULLY UNDERSTAND THE ABOVE WAIVER AND RELEASE OF ALL CLAIMS AND INTEND TO BE LEGALLY BOUND BY SAME.

BOTH PARENT/GUARDIAN SIGNATURES REQUIRED