Turning Point 2019-2020 Tutoring

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2nd - 6th Grade
September 16th - May 21st
MONDAYS, TUESDAYS, and THURSDAYS, after school - 5:00pm
$25 to Register

CHILD'S First and Last Name: *

Boy or Girl *

Boy

Girl

School and teacher's name: *

Grade for the 2019-2020 school year: *

Birth Date: *

YYYY

Address, Apartment #, City and Zip code: *

Parent/Caregiver name(s): *

Cell Phone #: *

Email: *

My child qualifies for Free and Reduced Lunch

My child does NOT qualify for Free and Reduced Lunch

Required

Ethnicity: *

My child is an immigrant or refugee or a new arrival to the U.S

Language(s) spoken at home: *

Medical and Emergency

Food Restrictions:

Does child have a special need/disability/medical condition? *

Yes

If yes, please describe:

Emergency contact, in case we can't reach you. Name and cell phone: *

Health Insurance Company and Policy #: *

Emergency Treatment Release

In the event that I cannot be contacted, I give my consent for Turning Point Seattle staff to administer first aid and call for emergency medical help. I consent for medical procedures to be performed for my child by a licensed physician or hospital if deemed necessary to protect my child’s health. Any expenses will be accepted by me.

Liability

I hereby hold Turning Point Seattle, its agents, officers and employees harmless from, and waive, release and discharge any claim or cause of action I have, or in the future may have, for injury, accident, illness, or death occurring during or by reason of this program, including being not limited to the administration of or the non-administration of said medical treatment, first and/or medication in accordance with the consent and/or information provided above. This release is limited to discharge in advance Turning Point Seattle, its agents, officers and employees from any and all liability even though that liability may arise out of negligence or carelessness on the part of the persons Turning Point mentions above.

I have carefully read this authorization/release and fully understand its contents and voluntarily consent to its terms and conditions.

Signature *

Bus Transportation Permission and Waiver Release

My child needs shuttle transportation from Parkwood or Meridian Park:

Mondays

Tuesdays

Thursdays

My child will walk home at 5:00pm after tutoring.

My child will be picked up at 5:00pm after tutoring.

Release of liability, waiver to claims, assumption of risks and indemnity agreement. By signing this legal document, you will waive certain legal rights, including the right to sue.

Liability: I hereby release and forever hold harmless Turning Point Seattle, their directors, officers, employees, representatives, and drivers from
responsibility for the lost or stolen property or bodily injury resulting from or attributed to the bus transportation.

I have carefully read this authorization/release and fully understand its contents and voluntarily consent to its terms and conditions.

Signature *

Photo Permission

Do we have permission to photograph or videotape your child:

For use in art projects or bulletin boards? *

Yes

For use in Turning Point Seattle brochures, on website or in newsletters? *

Yes

• I prefer that: *

only first names be used

a fictitious name be used

no name be used at all

Please return this form along with your $25 Registration Fee to Turning Point:

1315 N 160th Street, Shoreline, WA 98133 | lynn@turningpointseattle.org | 206.402.6960

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