Multiple Children Online Registration Form

Parent / Guardian Information

Name:
Family size:
Home phone:
Pager / Cell phone:
Address:
City:
State:
Zip:

Student #1 Information

Days in attendance: Monday Tuesday Thursday Friday
Last name:
First name:
Check here if same address as Parent / Guardian
If child's address is different, please tell us your child's address below:
Address:
City:
State:
Zip:
Gender:
Race:
Current grade in school:
Current school:
School city:
School state:
Current homeroom teacher:
Has student repeated any grades? Yes No
If yes, please give specific reasons (i.e. health problems):

Subject area(s) for tutoring (check all that apply):
Reading / Spelling / English
Math
Science
Social Studies

Student #1 Medical Information

Does your child:
Have special needs? Yes No
Have health problems? Yes No
If yes, please list:

Take medications? Yes No
If yes, please list all medications:

Please provide us with the name, addresss, and phone number of your child's physician or health clinic:

Hospital preferred for emergency treatment:

Health insurance policy name and plan number:

Student #2 Information

Days in attendance: Monday Tuesday Wednesday Thursday
Last name:
First name:
Check here if same address as Parent / Guardian
If child's address is different, please tell us your child's address below:
Address:
City:
State:
Zip:
Gender:
Race:
Current grade in school:
Current school:
School city:
School state:
Current homeroom teacher:
Has student repeated any grades? Yes No
If yes, please give specific reasons (i.e. health problems):

Subject area(s) for tutoring (check all that apply):
Reading / Spelling / English
Math
Science
Social Studies

Student #2 Medical Information

Does your child:
Have special needs? Yes No
Have health problems? Yes No
If yes, please list:

Take medications? Yes No
If yes, please list all medications:

Please provide us with the name, addresss, and phone number of your child's physician or health clinic:

Hospital preferred for emergency treatment:

Health insurance policy name and plan number:

Student #3 Information

Days in attendance: Monday Tuesday Wednesday Thursday
Last name:
First name:
Check here if same address as Parent / Guardian
If child's address is different, please tell us your child's address below:
Address:
City:
State:
Zip:
Gender:
Race:
Current grade in school:
Current school:
School city:
School state:
Current homeroom teacher:
Has student repeated any grades? Yes No
If yes, please give specific reasons (i.e. health problems):

Subject area(s) for tutoring (check all that apply):
Reading / Spelling / English
Math
Science
Social Studies

Student #3 Medical Information

Does your child:
Have special needs? Yes No
Have health problems? Yes No
If yes, please list:

Take medications? Yes No
If yes, please list all medications:

Please provide us with the name, addresss, and phone number of your child's physician or health clinic:

Hospital preferred for emergency treatment:

Health insurance policy name and plan number:

Emergency Contact Information

In the case of an emergency, please contact or release my child to the following individuals:

1. Name of contact:
   Phone:
   Relationship:
   
   
2. Name of contact:
   Phone:
   Relationship:
   
   
3. Name of contact:
   Phone:
   Relationship: