Student Application

Student(s) Information

Student 1

First Name*:

Last Name*:

School*:

Grade*:

Date of Birth*:

Please indicate any special needs the student may have:

Attending Sibling (if applicable)

First Name:

Last Name:

School:

Grade:

Date of Birth:

Please indicate any special needs the student may have:

Attending Sibling (if applicable)

First Name:

Last Name:

School:

Grade:

Date of Birth:

Please indicate any special needs the student may have:

Parent(s) or Guardian(s) Information

Note: Please advise us of any changes regarding custody of the student.

Parent / Guardian 1

First Name*:

Last Name*:

Relationship to the student:*:

Street Address 1*:

Street Address 2:

City*:

State*:

Zip Code*:

Primary Phone*:

Secondary Phone*:

Other Phone:

Email*:

Parent / Guardian 2

First Name:

Last Name:

Relationship to the student:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

Primary Phone:

Secondary Phone:

Other Phone:

Email:

Background Information

Note: Please advise us of any changes regarding custody of the student.

Language(s) Spoken at Home*:

Race / Ethnicity (optional):

American Indian or Alaska Native
Asian, Asian Indian, Hawaii Native, or Pacific Islander
Black, African, or African American
Caucasian
Hispanic/Latino
Other

Please list any existing medical conditions and allergies the student(s) has or has previously had (including medication, food, and latex/materials allergies)*:

Please indicate the name and dosage of any medication, vitamins, or herbal treatments the student is currently taking (should the student change medications and/or doses, please notify us so we can keep our records up to date):

Please Note

826CHI is a tutoring center, where students may come to work on and receive assistance with school or individual work. Although students are encouraged to feel at home while in the center, they are also expected to have homework to do, and to be respectful of their surroundings. We reserve the right to ask students we feel are being too disruptive to leave.

Please understand that 826CHI is a tutoring center and should not be considered an alternative to day care or babysitting services. While we will do our best to accommodate any student that comes to the center, we do have a limited amount of space. As a result, drop-in tutoring operates on a first-come, first serve basis. The tutoring center closes promptly at 5:30pm every day. Parents are responsible for making any necessary arrangements for getting their child home.

Release*

I accept

Informed Consent and License Agreement

Permission to reprint student work

I accept

Photo, Video & Radio Footage Permission

I accept

* Required fields