After-School Tutoring Program Waiver Form

Student Information

Student Name Grade Parent/Guardian Name Phone Number Email

Emergency Contact

Emergency Contact Name Emergency Phone Number

Medical Information

Allergies / Medical Conditions

Waiver & Release

I, the undersigned parent or guardian, acknowledge that participation in the After-School Tutoring Program is voluntary and understand that the program staff will take all reasonable precautions to protect the safety and well-being of my child.

I hereby release and hold harmless the organizers, staff, and venue from all liability for any injury, loss, or damage to person or property that may arise from participation in this program.

I agree to the terms and conditions above.

Parent/Guardian Signature

Date