Turning Point 2020-2021 Tutoring Registration
2nd - 6th Grade
September 28th - May 27th
MONDAYS, TUESDAYS, and THURSDAYS, after school - 5:00pm
$25 to Register
* Required
CHILD'S First and Last Name:
*
Your answer
Boy or Girl
*
Boy
Girl
School and teacher's name:
*
Your answer
Grade for the 2020-2021 school year:
*
Your answer
Address, Apartment #, City and Zip code:
*
Your answer
Parent/Caregiver name(s):
*
Your answer
Cell Phone #:
*
Your answer
Email:
*
Your answer
*
My child qualifies for Free and Reduced Lunch
My child does NOT qualify for Free and Reduced Lunch
Required
Ethnicity:
*
Your answer
My child is an immigrant or refugee or a new arrival to the U.S
Language(s) spoken at home:
*
Your answer
Medical and Emergency
Food Restrictions:
Your answer
Does child have a special need/disability/medical condition?
*
Yes
No
If yes, please describe:
Your answer
Emergency contact, in case we can't reach you. Name and cell phone:
*
Your answer
Health Insurance Company and Policy #:
*
Your answer
Emergency Treatment Release
In the event that I cannot be contacted, I give my consent for Turning Point staff to administer first aid and call for emergency medical help. I consent for medical procedures to be performed for my child by a licensed physician or hospital if deemed necessary to protect my child’s health. Any expenses will be accepted by me.
Liability
I hereby hold Turning Point, its agents, officers and employees harmless from, and waive, release and discharge any claim or cause of action I have, or in the future may have, for injury, accident, illness, or death occurring during or by reason of this program, including being not limited to the administration of or the non-administration of said medical treatment, first and/or medication in accordance with the consent and/or information provided above. This release is limited to discharge in advance Turning Point, its agents, officers and employees from any and all liability even though that liability may arise out of negligence or carelessness on the part of the persons Turning Point mentions above.
I have carefully read this authorization/release and fully understand its contents and voluntarily consent to its terms and conditions.
Signature
*
Your answer
Bus Transportation Permission and Waiver Release
My child needs shuttle transportation from Parkwood or Meridian Park:
Mondays
Tuesdays
Thursdays
My child will walk home at 5:00pm after tutoring.
My child will be picked up at 5:00pm after tutoring.
Release of liability, waiver to claims, assumption of risks and indemnity agreement. By signing this legal document, you will waive certain legal rights, including the right to sue.
Liability: I hereby release and forever hold harmless Turning Point, their directors, officers, employees, representatives, and drivers from
responsibility for the lost or stolen property or bodily injury resulting from or attributed to the bus transportation.
I have carefully read this authorization/release and fully understand its contents and voluntarily consent to its terms and conditions.
Signature
*
Your answer
Photo Permission
Do we have permission to photograph or videotape your child:
• For use in art projects or bulletin boards?
*
Yes
No
• For use in Turning Point brochures, on website or in newsletters?
*
Yes
No
• I prefer that:
*
only first names be used
a fictitious name be used
no name be used at all
Please return this form along with your $25 Registration Fee to Turning Point:
1315 N 160th Street, Shoreline, WA 98133 |
lynn@turningpointseattle.org
| 206.402.6960
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