Release of Liability Forms for Tutoring in Home - PDF by vlp17176


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									             SAT Prep
       High School Tutoring
          A SAGE program sponsored by the Plainfield Grassroots CDC

                     Winter 2010 Session
           Saturdays, 10:00 AM – 1:00 PM
                         10 Week Session
             January 23rd to March 27th

             St. Mark’s Episcopal Church
          1430 Park Avenue, Plainfield NJ 07060

             Open to All 9th to 12th Graders
                                Cost: $50.

           Make checks payable to: Plainfield Grassroots CDC

This program offers small group tutoring in SAT testing techniques as well as
tutoring in Math and English for high school students. For additional information,
go to (click on SAT Prep Program). Contact Dawn
McDonald (908-456-1233) or Gladston Hackett (908-591-5574) with question or for
more information.
Registration deadline is January 15, 2010. Enrollment will be on a first come first
serve basis. Mail completed registration forms (attached) to Plainfield Grassroots
CDC, 1430 Park Avenue, Plainfield NJ 07060 or fax to 908-754-3723.
Registration fees are due at the first day of class.
Plainfield Grassroots Community Development Corporation

SAT Prep & High School Tutoring Program
                                   REGISTRATION FORM
                                                                                              Session: Winter 2010

                                         STUDENT INFORMATION

Name: ____________________________________________________________________                        Age: _________

Home Address: _____________________________________________________________________________

Home Phone: _________________________________ Cell Phone: _________________________________

Email address: _____________________________________________________________________________

School: _________________________________________________________________                     Grade: _________

Have you taken the SAT before? YES | NO         If yes, what were your scores? ___________________________
                                                                                 Math | Reading | Writing

When are you planning to take the SAT? _________________            What is your target score? ______________

How did you learn about this program? _________________________________________________________

I agree to obey the rules of this program. I agree to be always courteous respectful to the teachers and other
students. I will arrive for class on time and will come prepared to work hard in every class.

Signed: _____________________________________                              Date: _________________________


Name(s): _________________________________________________________________________________

Cell Phone: _________________________          Email address: ________________________________________

Student’s Health Concerns: ___________________________________________________________________

I, ____________________________, hereby give my consent for the student named above to participate in the
SAGE SAT Prep & High School Tutoring program. I hereby release the Plainfield Grassroots CDC, its officers,
directors, members, program volunteers, agents, advisors and sponsors from any and all liability in connection
with his/her participation. Plainfield Grassroots CDC is hereby given my permission to allow the administration
of emergency treatment to my child if needed.

Signed: ________________________________________                           Date: _______________________

                                     Make checks payable to
                                   Plainfield Grassroots CDC

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