Problem Solved Tutoring- Katelynn Petersen
2019-2020 High School Registration Form
Algebra I
Algebra II
Email address *
Student first name *
Your answer
Student last name *
Your answer
Student's birthday *
MM
/
DD
/
YYYY
Student's grade *
Parent(s) first and last name(s) *
Your answer
Mailing Address *
Your answer
Mother's phone number
Your answer
Mother's Email address
Your answer
Father's phone number
Your answer
Father's Email address
Your answer
Home Address
Your answer
Algebra A, Algebra B
Space is limited. You will receive an email confirmation of your student's acceptance into class or placement on the wait list.

In the event that classes meet maximum enrollment your student will be placed on a waiting list.

Fees include the building use, most curriculum and some supplies. Students will need basic supplies & some project supplies for all classes.
Enrollment: *
Required
Please read and check all the following boxes *
Required
Billing *
Which charter or correspondence program are you with?
Who is your sponsor or contact teacher? *
Your answer
Media Release
I, the legal parent/guardian of the minor listed above, give Problem Solved Tutoring, Katelynn Petersen Staff, permission to use audio/video footage and photographic images that include my student and/or my student's work. Media may be used for work samples, Lighthouse Learning publications (such as Facebook, flyers, posters, website, slide shows, etc.) Student’s names will not be listed on any images other than work samples supplied to families and/or sponsor teachers.
*
Required
Special Concerns
Please list any medical or other needs that the instructor should be aware of. (allergies, asthma, learning challenges, etc.)
Your answer
Emergency Contact
Please list a name and phone number of someone that we can contact in the event of an emergency in which we cannot reach you.
First and Last name and phone number *
Your answer
Permission
I give my permission to my student to fully participate in all classes that they are registered for (excluding anything listed in "special concerns", above.)
Release of Liability
I understand that although the students will be supervised by Problem Solved Tutoring, Katelynn Petersen Staff, contractors, and/or volunteers, I do assume the risk in my student’s participation in classes

I acknowledge that I will not seek to have the Problem Solved Tutoring, Katelynn Petersen Staff, contractors held liable in the
event that any accident, injury, loss of property or any other circumstance or
incident occurs during or as a result of my son’s/daughter’s participation classes. This release of liability includes accident, injury, loss, or damages to
the student, as well as, to other individuals or property which may result from the
student’s participation in the event. I hereby release and agree to hold harmless All Star Tutoring and Kelly Nagel its officials, agents and employees and volunteers, from any claims arising
out of my son’s/daughter’s participation in the event(s).
I have read and understand and accept all of the statements recited above and
accept full responsibility as described.

The information provided in this form is true and accurate. I agree to the permission and release of liability above. Please sign by typing your full name: *
Your answer
A copy of your responses will be emailed to the address you provided.
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