Group Solutions - Club Tutorial Enrollment Form

Club Tutorial Enrollment Form

Course Information
* Course Name:
* Tutor's Name:
* Tutor's Phone:		(888) 555-1212
* Tutor's Email:
* Day(s) of Week:
* Time:
* First Day of Class:
* Enrollment Fees:
* Materials Fees:
* Total Fees:
Student Information
Student One
* Student Name:			* Grade:
* Birth Date:		mm/dd/yyyy	* Gender:
Student's Cell Phone:		(888) 555-1212
Learning Disabilities or Challenges:
Additional Information about the Student:
Previous Related Coursework:
Student Two
Student Name:			Grade:
Birth Date:		mm/dd/yyyy	Gender:
Student's Cell Phone:		(888) 555-1212
Learning Disabilities or Challenges:
Additional Information about the Student:
Previous Related Coursework:
Student Three
Student Name:			Grade:
Birth Date:		mm/dd/yyyy	Gender:
Student's Cell Phone:		(888) 555-1212
Learning Disabilities or Challenges:
Additional Information about the Student:
Previous Related Coursework:
Parent Information
* Parents' First Names:
* Parents' Last Name:
* Street Address:
* City:
* Zip:
* Home Phone:		(888) 555-1212
Fax:		(888) 555-1212
Email:
Father's Employer:
Father's Occupation:
Father's Work Phone:		(888) 555-1212
Father's Cell Phone:		(888) 555-1212
Mother's Employer:
Mother's Occupation:
Mother's Work Phone:		(888) 555-1212
Mother's Cell Phone:		(888) 555-1212
Policy Affirmations
	* We have read the Club Tutorials Handbook and will take the email quiz (review of the handbook) before August 1.
	* We agree to comply with the modesty policy.
	* We agree to comply with the discipline policy.
	* We agree to pay study hall fees if we arrive late in picking up our student (or if there is a time lapse between classes).
	* We agree to contribute 4 hours to Club Tutorials. We are most likely interested in:
	* Membership Form for Group Solutions must be completed for each Club year. If your family is concurrently enrolled in Calvary Class Day, your Membership Form has been completed and submitted. Membership Application has been completed and submitted.
	* Membership Fees for Group Solutions are required for each school year. If your family is concurrently enrolled in Calvary Class Day, your Membership Fees have been paid. Membership Fees have been paid.
Authorization for Medical Treatment
	* I (we) hereby grant the tutors/administrators of Group Solutions for Christian Home Educators permission to take whatever steps they deem necessary to obtain emergency medical care for my child. These steps may include, but are not limited to, the following: Attempting to contact a parent or guardian, Attempting to contact my child’s physician or another physician, if my child’s physician is not reached, or Having my child taken to an emergency room by private vehicle or ambulance I(we) agree that any expense incurred in the attempt to provide emergency care for my child will be my/our responsibility as the noted parent/guardian on this Enrollment Form. I (we) also authorize the physician in charge to provide whatever treatment is necessary.
Medical Insurance Information
Medical Insurance Company Name:
Medical Insurance Company Address:
Medical Insurance Company Phone Number:		(888) 555-1212
Group #:
Subscriber #:
Physician's Name:
Physician's Phone:		(888) 555-1212

Web Design by EyeLight Media