Program Consent Form
This will take about 10 minutes to complete and must be completed in one sitting.
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Student Last Name, First Name *
Student Date of birth
MM
/
DD
/
YYYY
Student Age
Student Grade Level
Student School (if homeschooled indicate that) *
Student Gender *
Student Race *
City *
State *
What mode of tutoring do you prefer?
Are you interested in group tutoring or individual tutoring?
Clear selection
Do you need mostly homework help tutoring or enrichment activities? *
Which day(s) do you prefer?
Are you interested in fully funded educational field trips?
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Parent/Guardian Last Name, First Name *
Parent/Guardian Number *
Parent/Guardian Email *
Life-Threatening Allergies (Check all that apply) *
Required
Dietary Restrictions (Check all that apply) * *
Required
Medical Conditions that you want us to be aware of (Check all that apply) *
Required
T-Shirt *
I give Narrow Path Outreach permission to obtain Emergency Medical Treatment. *
Media Consent: I, the parent or guardian, hereby consent to the use of my photograph or likeness in any publication, videotape, pamphlet or promotion by Narrow Path Outreach Incorporated or other agencies which are promoting or furthering the mission of Narrow Path Outreach Incorporated. I understand that I will not receive separate compensation or consideration from Narrow Path Outreach Incorporated or anyone else for the permission granted in this Consent nor for the actual publication or use of my photograph or likeness. By signing this Consent, I understand I am releasing Narrow Path Outreach Incorporated from any and all liability that may occur as a direct or indirect result of my photograph, the release of my identity, or the public relations materials, including but not limited to the use of any quotations. I give Narrow Path Outreach permission Media consent. *
To try to keep us and your child safe, mask are required for group sessions. Are you willing to adhere to this?
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Additional questions or concerns?
By checking this box you that all of the information you entered in this form is true. *
Required
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