2021 Student Application
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Email *
Which location are you interested in?
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Student's Name
Date of Birth
Does your child have any behavioral issues?
Are there any subjects in particular that your child needs to focus on?
What school does your child attend?
Has your child ever been retained (and if so, in which grade)?
Is your child enrolled in special education classes?
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Does your child have an I.E.P (Individualized Education Program?
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Student lives with:
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Parent's Name
Parent's Phone Number
Parent's Email address
Annual Household Income *
Number of people living in your household
Languages spoken at home
Does your child have any medical conditions that Northstar should be aware of (asthma, allergies etc.)?
Please identify any medications your child takes that Northstar should be aware of:
I give my permission for Northstar Tutoring to access my child's report card and standardized test scores.
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I give my permission for my child to attend field trips with Northstar Tutoring staff or volunteers.
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I give my permission for Northstar Tutoring to use photos or video of my child to promote Northstar Tutoring.
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In case there is any need for Northstar Tutoring to contact me, I agree to be reachable at the phone number provided above during each tutoring session or other Northstar event that the student attends (please initial below).
Should it be necessary for my child to have medical or emergency treatment while participating in an activity with Northstar, I hereby give Northstar Tutoring personnel permission to use their judgment in obtaining medical services, and I give permission to the physician selected by Northstar Tutoring personnel to render medical treatment deemed necessary and appropriate by the physician (please initial below).
All persons participating in activities of Northstar Tutoring are deemed to have waived all claims against Northstar Tutoring, it's directors, officers, staff and volunteers for injury, accident, illness or death occurring or by reason of a Northstar Tutoring related activity. I acknowledge that my child may be exposed to significant risk by participating in Northstar Tutoring activities. I have read and understood the foregoing statement and agree to assume the responsibility stated and waive all claims to the full extent permitted by law (please initial below).
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