2992 Main Street West, Snellville, GA 30078 Suite # 108 Ragine@soareducationalservices.com 678-756-2488

Parent Registration Form

Parent and Student Information

Parent First Name *

Parent Last Name *

Address

City

State

Zip Code

Email *

Phone Number *

Student First Name

Student Last Name

Current School

Current Grade

My goal is that a tutor will help my student:

Please rate your student by subject/activity (1-weakness 10-strength)

Math

Comment

Reading

Comment

Writing

Comment

History

Comment

Science

Comment

Test Taking

Comment

Organization

Comment

How much time do you spend helping your student complete homework?

While doing homework my student does: (Check all that applies)

Does homework right after school

Does homework in the early evening

Does homework late at night

Avoids works in difficult subjects

Listens to music

Surfs the internet

Gets sleepy

Comment

Expected start date?

Emergency Contact Information - Alternate Pickup/Release

First Name

Telephone

Last Name

Relation to Child

First Name

Telephone

Last Name

Relation to Child

Please list any other allergies, current medications, inhalers, etc. Please note that you must supply medication labeled with child’s name and detailed instruction prior to your child attendance.

My child,

,has permission to fully participate in Soar Educational Services activities. I as parent/legal guardian, do hereby grant the Soar Educational Services staff and designated adults permission to transport my children during planned field trips. I also grant Soar Educational Services and its staff the right to authorize emergency medical treatment for my child in the event that I or my designated representative cannot be reached. I agree to hold harmless Soar Educational Services and its agents from liability resulting from an accident.

Parent/Guardian Initials *

I will not hold Soar Educational Services liable for any damages/accidents associated with the transportation to and from field trips. I understand that the Soar Educational Services and its staff will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as a parent/guardian. Unless otherwise informed by the parents and/or legal guardians, your child will be taken to Eastside Medical Center of Snellville if a medical emergency occurs which requires professional medical attention.

Parent/Guardian Initials *

Video/Photo Release

I hereby grant permission to Soar Educational Services, and its employees, agents, and assignees, the right to photograph my child or use their picture for purposes of advertising, publicity, trade, or otherwise, as still photographs, transparencies, motion pictures, television, web images, or other media or means of reproduction, transmission, or exhibition. I release Soar Supplemental Program of Educational Skills, its employees, agents, associates, successors, and assignees from any and all claims for damages or compensation for any claims based on the use or sale of said materials.

Yes, I do

No, I don't

Liability Release

I believe the information provided above is a complete and accurate statement of the physical and behavioral factors which may affect my child’s participation in this program.

I hereby grant permission for my child to take part in the services provided by Soar Educational Services. I also agree, on behalf of myself or my child, not to make any claims of any kind against Soar Educational Services or any of its employees or agents for any loss or injury that my child might sustain while engaged in the activities sponsored by the program.

Soar Educational Services and its employees are not responsible for lost or damaged personal property.

Signature of Parent/Guardian *

Date *

SUCCESS IN EVERY STUDENT

Parent Registration Form

Parent and Student Information

Emergency Contact Information - Alternate Pickup/Release

Video/Photo Release

Liability Release