GENESIS  Tutoring
                                                                    GENESIS Learning Services
                                      135 Bastille Way - Fayetteville, GA 30214 -(678) 519- 3776
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GENESIS Tutoring
Parent Name *
First and last name
Child(ren) Name *
Address *
Email *
Phone number *
What grade is your child?
What school does your child attend?
Please indicate in which area help is needed
I would like to request the following day(s).
I would like to request the following time(s).
I would like to be invoiced...
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Emergency Contact #1 This person is also permitted to check my child out. *
Emergency Contact #2 This person is also permitted to check my child out.
Medical Release Information: List Company, Policy number, and Primary Physician *
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
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Is your child allergic to any type of food or medication? If yes, please list.
The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.
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Photo Release: I hereby give permission for my child to be photographed during tutoring. I understand the photos will be used to keep a journal of activities, to share during powerpoint presentations and/or reports for promotional purposes including flyers, brochures, newspaper and on the internet.  I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed.
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