Student First Name *

Student Last Name *

Student Email Address

Student Cell Phone Number

Gender *

School Name *

Student's Grade *

Parent/Guardian's Full Name *

Parent/Guardian's Email *

Parent/Guardian's Cell Phone *

Emergency Contact Name (2nd Parent/Guardian or others) *

Emergency Contact Cell Phone *

Emergency Contact Email *

Which city do you live? *

What subject would you like to be tutored in? *

What's your child's interest? *

Is there anything you would like us to know about your child or preference about the tutor?

How did you hear about us? *

I, the parent and/or legal guardian, hereby represent that I consent to my child or ward's participation in the activities and/or events. I agree individually and on behalf of my child or ward, to WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons including Youth4Good Foundation, and/or their employees, volunteers, officials, sponsors and other representatives. I further agree to hold harmless each and all of the parties referred to above from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the child or ward and the parents or legal guardians.I hereby authorize and consent to the use of my child/ ward's visual image by Youth4Good Foundation for appropriate purposes, including but not limited to: still photography, videotape, electronic and print publications and websites. I give this consent with no claim for payment. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.