Reading Clubs Registration Form

Child’s Name*

Parent Name*

Address*

City / State / Zip Code*

Cell Phone*

Email*

Emergency Contact Name

Emergency Contact Phone*

Date of Birth*

Food Allergies*

Name of School

Please select the grade your child is entering*

K
1
2
3

The Traveling Tutor, LLC or Pre-K Academy may use photos or video of your child and/or quotes from you or your child or you in The Traveling Tutor, LLC/Pre-K Academy/Happy Hearts/your Reading Coach publications, websites and general media not to exclude advertisements or social media. I give the Pre-K Academy teachers permission to give my child NUT FREE food as it pertains to the lessons. Please list all food allergies above.

Signature of Parent/Guardian of Minor*

Date

In consideration of the academic services to be provided by The Traveling Tutor, LLC/Pre-K Academy/Happy Hearts/your Reading Coach on behalf of my child, myself, my heirs, personal representatives and assigns I do hereby release, waive, discharge, and covenant not to sue or bring a claim of any type against Traveling Tutor, LLC, its owners, officers, employees, agents and lessors from and against any liability for any and all claims including, without limitation, negligence or premises liability resulting in personal injury, accidents, illnesses or property loss arising from, but not limited to, my child’s participation in the services.

Signature of Parent/Guardian of Minor*

Date

12-week session is $300 (plus a $5 credit card transaction fee)
There are no refunds for missed days.

12-week session*

Price:

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Online Payment

Card Details

Cardholder Name

Consent*

I give the PKA permission to text me pictures/video of my child.*

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Phone

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