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Reading Clubs Registration Form
Child’s Name
*
Parent Name
*
Address
*
City / State / Zip Code
*
Cell Phone
*
Email
*
Emergency Contact Name
First
Emergency Contact Phone
*
Date of Birth
*
MM slash DD slash YYYY
Food Allergies
*
Name of School
Please select the grade your child is entering
*
K
1
2
3
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/Happy Hearts/your Reading Coach
publications, websites and general media not to exclude advertisements or social media. I give the Pre-K Academy teachers permission to give my child
NUT FREE food
as it pertains to the lessons. Please list all food allergies above.
Signature of Parent/Guardian of Minor
*
Date
MM slash DD slash YYYY
In consideration of the academic services to be provided by
The Traveling Tutor, LLC/Pre-K Academy/Happy Hearts/your Reading Coach
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 services.
Signature of Parent/Guardian of Minor
*
Date
MM slash DD slash YYYY
12-week session is $300 (plus a $5 credit card transaction fee)
There are no refunds for missed days.
12-week session
*
Price:
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Online Payment
Card Details
Cardholder Name
Consent
*
I give the PKA permission to text me pictures/video of my child.
*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
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