Private Tutoring and Coaching Registration Form

Child’s Name*

Parent Name*

Address*

City / State / Zip Code*

Cell Phone*

Email*

Emergency Contact Name

Emergency Contact Phone*

Current Grade*

Child’s Age*

Date of Birth*

Name of School

Teacher’s Name

Allergies*

Learning Diagnosis*

Medical Concerns*

Medications*

Please check what subject areas you would like included in your child’s curriculum.*

Reading
Writing
Spelling
Math
Social/Emotional Skills (Brainwise ^TM Program)

Please fill in your preferred days and times. (Days and times are subject to availability.)*

How many tutoring sessions would you like per week? (We recommend bi-weekly in the summer.)*

Learning Diagnosis:

Please Check which program you would like:*

The Boost (once a week) COST is $75 per session
The Super Boost (twice a week) ) COST is $70 per session

Payment Option

MONTHLY CREDIT CARD PAYMENT* (will be subject to a 3.0% processing fee)
MONTHLY ELECTRONIC CHECK PAYMENT* (no added fee)

This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes.

Credit Card*

Card Details

Cardholder Name

Bank Name*

Account Number*

Routing Number*

*Once we enter your bank information, you will see 2 small deposits in your account from The Traveling Tutor LLC. Please send us the amounts so we can verify your account. First Month Only.

CANCELLATION POLICY: We have reserved a special day and time just for your child. Please be advised that we do charge our full session fee for all missed tutoring appointments. If you plan to be out of town, please give us a minimum of 5-days’ notice and we will do our best to reschedule your sessions. In the event that your child is ill or is showing any symptoms such as runny nose, cough, fever, body aches, please give us 24 hours’ notice (if possible). You will not be charged a cancellation fee. Instead, we will reschedule your in-person session (when possible) and/ or switch to Zoom.

Initial

LIABILITY WAIVER: In consideration of the tutoring services to be provided by Your Reading Coach/Traveling Tutor, LLC, on behalf of my child, myself, my heirs, personal representatives and assigns I do hereby release, waive, discharge, and covenant not to sue or bring a claim of any type against Traveling Tutor, LLC, its owners, officers, employees, agents and lessors from and against any liability for any and all claims including, without limitation, negligence or premises liability resulting in personal injury, accidents, illnesses or property loss arising from, but not limited to, my child’s participation in the tutoring services. Purpose, limitations, and risks of nature of relationship: Tutoring, like most endeavors in the helping professions, is not an exact science. While the ultimate purpose of tutoring is to enhance your child’s school performance through a process of regular assessment and an individualized tutoring program, there are no guarantees that the tutoring provided will increase your child’s school performance. There are often conditions within a school environment that we cannot control including, but not limited to, testing environment, test format, and teacher directions. We will not diagnose learning disabilities or any medical conditions that may interfere with your child’s growth. If any issues come up, they should be handled by a physician or licensed educational psychologist.

Initial

COVID RELEASE: I hereby acknowledge the health risks and dangers associated with the transmission of the COVID-19 virus, and other communicable diseases, and recognize that exposure to the COVID-19 virus, or other communicable diseases, could occur while my child is participating in tutoring sessions. I, have read and fully understand and acknowledge the contents of the Release and agree that I am voluntarily waiving, releasing, indemnifying and discharging The Traveling Tutor LLC DBA Your Reading Coach of any damages, by participation in tutoring services at the home of Jill Leshin at 6015 East Pershing of exposure or transmission of the COVID-19 virus or other facilities. My signature below is confirmation that I have read and fully understand and acknowledge the contents of the Release and agree that I am voluntarily waiving, releasing, indemnifying and discharging Reading Coach/Traveling Tutor LLC or Jill Leshin or any of her employees of any damages to my child or anyone who drops off and picks up my child from tutoring sessions.

Initial

FOOD AND PICTURE WAIVER: I give The Reading Coach/Traveling Tutor LLC and/or her associates permission to give my child food as it pertains to the sensory learning lessons. I understand that the food may contain sugar and may not have a high nutritional content. Children will be given a very limited amount of any food that contains sugar such as pancake syrup, frosting, cereal, pretzel sticks and licorice. I have listed all of my child’s food allergies below. If my child is diagnosed with a new food allergy, I agree to notify The Traveling Tutor LLC as soon as possible. The Traveling Tutor, LLC or Pre-K Academy may use photos or video of your child and/or quotes from you or your child or you in The Traveling Tutor, LLC/Pre-K Academy publications, websites and general media not to exclude advertisements or social media.

Initial

Signature of Parent/Guardian of Minor*

Date

Consent*

I give the PKA permission to text me pictures/video of my child.*

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