Student Information Form
Welcome to CLASS!
We look forward to working with you to help you reach your academic goals.
Please take a moment to complete the Student Information Form. All information is confidential and is used for recording and scheduling purposes.
If you have more than one student, please select "Add Student" at the bottom of the form to add additional students.
Please complete the entire form;
all fields are required
. You will be notified immediately upon successful submission of your form that it has been received.
Please do not resubmit your information form; doing so could cause a delay in processing it.
If you have any questions, please call us at (901) 417-6636 or email us at
[email protected]
.
PARENT/GUARDIAN INFORMATION
Parent/Guardian First Name(s)
Parent/Guardian Last Name
Parent/Guardian Email
Parent/Guardian Home Phone
Parent/Guardian Mobile Phone
Parent/Guardian Address
City
State
Zip
Parent preferred method of contact
Email
Phone
Email & Phone
Parent preferred method to receive session notifications
Email
Text Message
Email & Text Message
STUDENT INFORMATION
Student First Name
Student Last Name
Student Email (If student has no email, please leave blank.)
Student Mobile Phone (If student has no mobile phone, please leave blank.)
School
Grade
Birth Date
Student preferred method to receive session notifications
Email
Text Message
Email & Text Message
For which academic area(s) are you seeking tutoring?
ACT Practice Test
ACT Prep
Literature & Reading Comprehension
Mathematics
Science
Social Studies
Spelling
Study Skills
Writing
EMERGENCY INFORMATION
Emergency Contact #1 Name & Number (other than parent/guardian listed above)
Emergency Contact #2 Name & Number (other than parent/guardian listed above)
Does your child have any allergies or health problems we should be aware of?
Is there any other information you would like us to know about your child?
CONSENT TO TUTOR
I understand that my child’s participation and attendance in the free tutoring program provided by Center for Learning and Academic Support Services, Inc., hereafter referred to as C.L.A.S.S., is voluntary and is a willing participant. I agree to abide by CLASS policies and procedures. I further agree to hold harmless C.L.A.S.S., as well of all of its employees, agents, representatives, etc. from all losses or claims arising out of my child’s participation in the C.L.A.S.S. tutoring program.
Select
I agree.
CLASS has my permission to contact or communicate with my child's school/teacher(s). I understand it is my responsibility to provide appropriate contact information to CLASS. Further, I will inform the teacher(s) that CLASS would like to communicate with them. (*NOTE: Teachers are not obligated to communicate with tutors and may not agree to do so.)
Select
CLASS has my permission to communicate with my child's teacher(s).
CLASS does not have my permission to communicate with my child's teachers.
STUDENT DRIVER RELEASE
My student will transport himself/herself to tutoring sessions and will not be accompanied by an adult. I give my child permission to sign-in and sign-out of CLASS for services rendered from CLASS. I understand that I will be notified if my child does not arrive at the tutoring sessions within 10 minutes of the scheduled time. I further agree to hold harmless CLASS, as well as all of its employees, agents, representatives, etc. from all losses or claims arising out of my child's participating in the CLASS tutoring program.
Select
I give my child permission to sign-in and sign-out of CLASS.
I do not give my child permission to sign-in and sign-out of CLASS.
How did you hear about C.L.A.S.S.?
Facebook
Twitter
Instagram
Website
Referral
Other
If you were referred, please tell us who referred you.
PHOTO RELEASE
MINORS (UNDER 18): The Center for Learning and Academic Support Services, Inc. has my permission to use my child’s photograph publically to promote the Center for Learning and Academic Support Services, Inc. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
Select
CLASS has my permission to use my child's photograph.
CLASS does not have my permission to use my child's photograph.
ADULTS (OVER 18): The Center for Learning and Academic Support Services, Inc. has my permission to use my photograph publically to promote the Center for Learning and Academic Support Services, Inc. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
Select
CLASS has my permission to use my photograph.
CLASS does not have my permission to use my photograph.
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