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Champion Tutorial Program
REGISTER NOW!
Each session is designed to help the student build confidence and their ability to master the skills in Reading, Writing & Speaking
Tuesdays & Thursdays
6:30pm - 8:00pm
Tutoring Enrollment Form
Date
School and Grade
Child First Name
Child Last Name
Address
City
State
Zipcode
Mother First Name
Mother Last Name
Cell Phone Number
Work Phone Number
Home Phone Number
Mother Email
Father First Name
Father Last Name
Cell Phone Number
Work Phone Number
Home Phone Number
Father Email
Does the child have any known allergies?
Choose One
Yes
No
Please give any information concerning your child which will be helpful in his/her experience in group setting (such as play, eating and, special fears, special likes or dislikes).
Emergency Contacts (List Names, Numbers and Relation)
Release and Indemnity Agreement: I understand that participating in the class (es) or program (s) selected involves risk of injury. These risks include inclement weather, accidents while traveling, equipment problems or failures, contacts with actions of other participants, slips/trips/falls, and musculoskeletal injuries, among others. I choose for myself or for my child to participate in the selected programs despite the risks. By submitting the registration form, I acknowledge all risks of injury, illness and death and affirm that I have assumed all responsibility of injury, illness or death in any way connected with participation in the program. I also agree for myself and for any child participant to follow all rules and procedures for the program and to follow reasonable instructions of the teachers and supervisors of the program. In return for the opportunity to participate in this program, I agree for myself and for my heirs, assigns, executors and administrators to release, acquit, waive and forever discharge any legal rights I may have to seek payment or relief of any kind from 180 Turn Church, its officers, employees, agents or its volunteers for injury, illness, death or property loss resulting from this program. If I am registering a child for a program, I agree that I am a parent, legal guardian, or am otherwise responsible for the child whose application I am submitting and that I release, waive, and discharge any legal rights that I may request on behalf of the child participant in the program. I also agree not to sue 180Turn Church, its officers, employees or agents and agree to indemnify 180Turn Church for all claims, damages, losses, or expenses, including attorney’s fees, if a suit is filed concerning an injury, illness or death to me or my child resulting from participation in the program. Permission is given for any emergency medical treatment which might become necessary and I agree to be responsible for the expense of medical treatment or service.
Image Release: I, the undersigned, hereby consent to allow the exclusive use of, and relinquish all rights to, photographs, recordings and reproductions in any manner (including but not limited to the use of photos, video and audiotapes) of the likeness, voice, and/or activities of the participant and further authorize 180Turn Church, its agents or assigns, to make unlimited use of such reproductions, including but not limited to print and/or electronically, broadcasting of the reproduction over radio, television, and on the internet with or without your name for any lawful purpose. I acknowledge that no compensation will be provided for such use by 180Turn Church. I understand that this Release shall remain in effect unless a subsequent written notification is provided to 180Turn Church.
Choose One
Yes, I'm ok with the Image Release
No, I'm NOT ok with the Image Release
Non-Discrimination Policy: It is the policy of 180Turn Church that we will not discriminate on the basis of sex, race, gender, color, ethnicity, national origin, age, religion, physical or mental disability.
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