2018-2019 STEMulates - Private/Group Tutoring Registration
Student Last Name *
Your answer
Student First Name *
Your answer
Date of Birth *
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In what grade is your student currently enrolled? *
In what school is your student currently enrolled? *
Your answer
There is a charge for our services. $15/hr for group tutoring (no more than 4 students per group). $25/hr for private tutoring. All tutoring is conducted by engineering professionals and students who meet a minimum requirement on testing. Are you willing to cover this cost? If no, please stop and contact our team to locate services that may better suit your needs. *
Would you prefer group or private tutoring? *
Availability *
Parent or Guardian's Name *
Your answer
Relationship to Student *
Email address for correspondence *
Your answer
Emergency Contact #1 (Name and Phone Number) *
Your answer
Emergency Contact #2 (Name and Phone Number) *
Your answer
Emergency Contact #3 (Name and Phone Number) *
Your answer
Past Medical History (ex: Epilepsy, Asthma, etc.) *
Your answer
Any accommodations needed to participate in our program? *
Your answer
Any medications? *
Your answer
Known allergies (food, medications, environments, etc.) *
Your answer
Child's Physician (name and number) *
Your answer
Any other pertinent medication information? We are not responsible for any type of medical/ambulance costs. *
Your answer
Does your student have any behavioral issues of which our staff should be aware? *
If yes, explain
Your answer
I authorize The Gaskins Foundation and/or their authorized agent to release publicly my child's name, including pictures and videotape for use related specifically to their achievements. *
My student has permission to attend all of The Gaskins Foundation c/o Cincinnati STEMulates activities. In consideration of the child’s participation in the program, we will release and hold harmless Gaskins Foundation’s Cincinnati STEMulates, Whitney Gaskins, The University of Cincinnati and all of their employees, officers, directors, agents, members, insurers, and associates, from any and all claims, of any sort, type, nature, or description, whether known or unknown, foreseen or unforeseen, which could be asserted against any of the above-listed entities or persons, and they expressly waive any and all such claims. Said release and waiver shall not apply to bar claims for intentional or willful conduct. *
I give The Gaskins Foundation/STEMulates the permission to transport my child to the hospital in the event of an emergency as deemed necessary by the staff of The Gaskins Foundation c/o STEMulates *
Preferred Hospital (we will try our best to accommodate) *
Your answer
By enrolling into the Gaskins Foundation, I am showing my commitment to enhancing our student's future while making it enjoyable. I have read and full understand these policies and procedures. *
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