Leap Ahead Tutoring Registration Form

Please complete this form to the best of your ability. We will use the information you provide to match your child with a tutor and will give your tutor the contact information listed below.

If you wish to register more than one child for tutoring, please complete a separate form.
Your Name (Parent/Guardian/Caretaker) Your Name (Parent/Guardian/Caretaker) First Last
Relationship to Child
Child's Name Child's Name First Last
If you wish to enroll more than one child, please complete a separate form for each
Child's Home Zip Code
What school does your child currently attend? Example: School #45 Mary McLeod Bethune
Child's Grade
Child's Race (Check all that apply)

Child's Race (Check all that apply) East Asian South Asian West Asian Southeast Asian Black/African American Native Hawaiian/Pacific Islander White Native American/Alaskan Native/Indigenous Race not listed Race not listed
What is the primary language used at home?

What is the primary language used at home? American Sign Language Arabic English Spanish Language not listed Language not listed
Child's Ethnicity

Child's Ethnicity Hispanic/Latinx Non-Hispanic/Latinx
Please enter the phone number and email we can best contact you at.
Your Phone Number Your Phone Number - ### - ### ####
Your Email
How do you prefer to be contacted?

How do you prefer to be contacted? Phone (Call) Phone (Text) Email
Which subject does your child need support in? Select all that apply.

Which subject does your child need support in? Select all that apply. Reading Writing Math Other Other
What support does your child need? Select all that apply.

What support does your child need? Select all that apply. Homework Help Study Skills Academic Support
Please list days and times that work for you and your child:
Is there anything you want us to know to best support your child?
Parent Consent/Media Release Agreement

Please read the consent agreement below before signing:

As the parent, guardian, or caretaker of the child registered above:
I agree to be the primary contact for Leap Ahead Tutoring and affirm that the contact information listed above is accurate. I understand that my contact information will be shared with the tutor to communicate, schedule, and set-up tutoring sessions.

I give Leap Ahead Tutors my consent to work privately with my child and understand that I can take part in any and all tutoring sessions with my child.

I give consent to Leap Ahead Tutoring to record every tutoring session for the safety and well-being of my child, for the use of program development, training, security, and available for me to watch upon my request as the guardian/caretaker of the child registered in this form. I give Leap Ahead Tutoring consent to share my child's recorded session outside of the program for promotional or educational purposes.

I affirm that I have read the program description and expectations, and I understand my responsibility as the guardian/caretaker to serve as the tutor’s contact with my child, to help set-up and run each virtual tutoring session if my child requires help.

I understand that Leap Ahead Tutoring values my child's safety and security, and completes background checks for each tutor upon hiring, requires that any tutor complete the Child Protection Policy, and related trainings (including but not limited to: ethics, professionalism, working with children, best practices, technology) prior to working as a tutor for my child.
I have read and agree to the terms and conditions of the media release and consent form above.
Please Type your name in the box below (this serves as your signature) Please Type your name in the box below
(this serves as your signature) First Last
I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Leap Ahead Tutoring Registration Form

Parent Consent/Media Release Agreement