Summer Tutoring Request & Contract - for Community and MCS Students
Registration form for Tutoring requests
Email address *
STUDENT INFORMATION
Student's First Name *
Your answer
Student's Middle Name *
Your answer
Student's Last Name *
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Student is Enrolled at Milpitas Christian School *
Student's grade level in the fall *
PARENT INFORMATION
Mother's First Name *
Your answer
Mother's Last Name *
Your answer
Mother's Cell Phone Number *
Your answer
Mother's Home Phone Number *
Your answer
Family MCS Account Number (NA if you don't have an account number) *
Your answer
Mother's Email *
Your answer
Mother's address - Street *
Your answer
Mother's Address - City *
Your answer
Mother's Address - State *
Your answer
Mother's Address - Zip Code *
Your answer
Father's First Name *
Your answer
Father's Last Name *
Your answer
Father's Cell Phone *
Your answer
Father's Home Phone *
Your answer
Father's Email *
Your answer
Father's Address - Street *
Your answer
Father's Address - City *
Your answer
Father's Address - State *
Your answer
Father's Address - Zip Code *
Your answer
TUTORING REQUEST
Tutoring availability
How many days per week would you like tutoring? *
When is your student NOT available for tutoring? *
Required
Which of the following is your child enrolled in *
Required
Billing Preference *
TUTORING FOCUS
What areas of focus would you like for your student? Check all that apply. *
Required
OTHER - GENERAL INFORMATION
Does your child have an IEP or 504 Plan?
Is there anything else you would like us to know about your child? *
Your answer
List any questions, concerns, or ideas here.
Your answer
HEALTH INFORMATION
Does you child have any allergies or conditions? If so please list them in the space provided.
Your answer
PHYSICIAN AND INSURANCE INFORMATION
Physician's Name
Your answer
Physician's Phone
Your answer
Insurance Carrier
Your answer
Policy Number
Your answer
Preferred Hospital
Your answer
Authorization to contact emergency services
I hereby authorize the Milpitas Christian School Staff to call emergency services in case of accident or acute illness, and to arrange for necessary emergency and surgical care, in the case I am not immediately available. Any qualified physician, or dentist, called by Milpitas Christian School may treat and do whatever is necessary for the well being of my child. It is understood that every effort will be made to notify me before the abe action is taken. I also agree to accept responsibility for the cost of the above medical or dental treatment.
Permission to Treat *
Today's date: *
MM
/
DD
/
YYYY
Electronic Signature (Full Name of Parent) *
Your answer
EMERGENCY CONTACT AND RELEASE INFORMATION
Mother is Emergency Contact *
Father is Emergency Contact *
Other Approved Adults - Permission to pick up and sign
Please enter the full name of adults who have permission to pick up and sign-out your student from tutoring. Please enter the person's legal name as provided on some form of picture ID (driver license, etc.)
Adult #1 - Full Name
Your answer
Adult #1 - Relationship to Student
Your answer
Adult #2 - Full Name
Your answer
Adult #2 - Relationship to Student
Your answer
Adult #3 - Full Name
Your answer
Adult #3 - Relationship to Student
Your answer
Emergency Release Procedure
Select an emergency release procedure as described below in the event of a school-wide emergency or disaster.
Options for emergency release procedure *
Electronic Signature of Parent or Guardian (full name) *
Your answer
Confirmation Email *
Your answer
Contract Agreement
By signing this form, you are agreeing to the terms of our tutoring program as described below.

1. One-on-one tutoring sessions are 45 minutes in length and are designed to meet the specific instructional and academic needs of the individual student.

2. Tutoring is held on campus during regularly scheduled school hours. After school sessions are dependant on tutor availability.

3. Tutoring sessions are scheduled by the Leaning Lab Director.

4. Fourteen (14) calendar day notice, in advance, is required to terminate the contract. The student account will be adjusted based on the actual number of scheduled sessions.

5. Fourteen (14) day notice will be given when the student is ready to graduate from the Learning Lab Program with account adjustments applied.

6. Tutoring reports will be issued at the end of the Summer Tutoring program via email.

7. Sessions missed may, or may not be able to be rescheduled.

8. Student accounts will be billed for unexcused absence from a session due to family vacation, medical or dental appointments, detentions, suspensions or non-MCS related activities or non-emergency conflicts.

Electronic Signature of Parent or Guardian (full name) *
Your answer
Confirmation Email *
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Milpitas Christian Schools. Report Abuse - Terms of Service