A Better Tomorrow Tutoring Registration Form

"I will be the change for a better tomorrow"

Free Tutoring Services for Grades K-12
A Better Tomorrow Tutoring Registration Form
Childs Name

First NameLast Name
Age
Parent/Guardians Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Numbers to Call Incase of Emergency & Relationship to the Child.
Contact Name

First NameLast Name
Relationship To Child
Phone Number

Area CodePhone Number
Contact Name

First NameLast Name
Relationship To Child
Phone Number

Area CodePhone Number
Password if someone else is picking up the child.
Does your child have any known emotional or behavioural problems? If Yes, please state in brief what and discuss this with program director.
Please give brief detail
Does your child have Epilepsy? If Yes, please advise program director.
Does your child have severe allergies/anaphylaxis. If your child requires an epi-pen, please make sure you are in the building.
Does your child have Asthma? If Yes, please advise program director & ensure they bring their inhaler.
Is your child taking any medication, if Yes please give details
Please give detail
Please complete the following to the best of your knowledge and discuss any specific concerns you have with me and together we can support your child.

Rows	Excellent	Good	Ok	Needs some extra support	Needs lots of extra support
Ability to be calm and peaceful at times.
Ability to deal with anxiety and stress.
Ability to express their feelings.
Self-esteem and self-confidence.
Ability to cope with feelings of Anger
Ability to openly show care and concern for themselves and others
Attention span.
Ability to listen
Sleep pattern.

How did you hear about A Better Tomorrow?
A Better Tomorrow program includes tutoring in various subjects like Math, English, Science, History and more, recreational activities like Basketball, Soccer, Poetry, Art, Music, Dance and field trips like Museums, Zoos, and more. Do you consent to your child being involved.
Signature
Date and Time
Should be Empty:

"I will be the change for a better tomorrow"