Which School Year or Summer Program are you registering for?* –None–Summer 20232023-2024
–None–ActivePendingInactiveFormerRejected
First Name*:  
Last Name*:  
Gender:       –None–MaleFemaleOther
Birth Date(MM/DD/YYYY)*:
Place of Birth:  
Primary Language:  

PLEASE ENTER INFORMATION ABOUT THE CHILD’S PARENT(S) AND/OR GUARDIAN(S)

Parent/Guardian-1
Child lives with Parent/Guardian-1:  
Parent/Guardian-1 First Name*:  
Parent/Guardian-1 Last Name*:  
Parent/Guardian-1 Primary Phone*:  
Parent/Guardian-1 Other Phone:  
Parent/Guardian-1 Other-2 Phone:  
Parent/Guardian-1 Email*:  
Parent/Guardian-1 Street Address*:  
Parent/Guardian-1 City*:  
Parent/Guardian-1 State*:  
Parent/Guardian-1 Zip*:  
Parent/Guardian-1 Relationship*:–None–MotherFatherOther

Parent/Guardian-2
Child lives with Parent/Guardian-2:  
Parent/Guardian-2 First Name:  
Parent/Guardian-2 Last Name:  
Parent/Guardian-2 Primary Phone:  
Parent/Guardian-2 Other Phone:  
Parent/Guardian-2 Other-2 Phone:  
Parent/Guardian-2 Email:  
Parent/Guardian-2 Street Address:  
Parent/Guardian-2 City:  
Parent/Guardian-2 State:  
Parent/Guardian-2 Zip:  
Parent/Guardian-2 Relationship:  –None–MotherFatherOther

PLEASE IDENTIFY ONE OR TWO EMERGENCY CONTACTS:

Emergency Contact 1:

Emergency-1 First Name*:  
Emergency-1 Last Name*:  
Emergency-1 Primary Phone*:  
Emergency-1 Other Phone:  

Emergency Contact 2:

Emergency-2 First Name:  
Emergency-2 Last Name:  
Emergency-2 Primary Phone:  
Emergency-2 Other Phone:  

PICK UP INFORMATION:

Homework House is drop-in program and children may sign in and out as they wish UNLESS you tell us otherwise. The staff and volunteers of Homework House leave promptly at the end of each session and are not responsible for children left after that time.  The volunteers and staff will not, under any circumstances, pick up or transport any child to or from home.

Agree with above Pick Up Information*:

–None–I AGREE with Pick Up TextI DO NOT AGREE with Pick Up Text

PLEASE ENTER INFORMATION ABOUT PEOPLE WHO ARE AUTHORIZED TO PICK UP THE CHILD

Please list all people authorized to pick up, including yourself and other parent if applicable.

Pick Up Person 1:

Pickup-1 First Name:  
Pickup-1 Last Name:  
Pickup-1 Primary Phone:  
Pickup-1 Other Phone:  
Pickup-1 Email:  

Pick Up Person 2:

Pickup-2 First Name:  
Pickup-2 Last Name:  
Pickup-2 Primary Phone:  
Pickup-2 Other Phone:  
Pickup-2 Email:  

Pick Up Person 3:

Pickup-3 First Name:  
Pickup-3 Last Name:  
Pickup-3 Primary Phone:  
Pickup-3 Other Phone:  
Pickup-3 Email:  

MEDICAL INFORMATION

Are there any current medical issues or concerns that may interfere
with your child’s studies or ability to participate in physical activities?*

–None–Yes – Student has issues that may interfere with studies or physical activitiesNo – Student does NOT have issues that could interfere with studies or physical activities

If so, please describe below:

List any allergies the Child may have or ‘None’*:  
List current Medications Child may be taking or ‘None’:  

Child’s Primary Care Physician:  
Child’s Primary Care Physician Phone:  

Child’s Health Insurance Company:  
Child’s Health Insurance Policy Number:  

AUTHORIZED TO SEEK MEDICAL ATTENTION
IF ANY MEDICAL ISSUES ARISE, I AUTHORIZE THE HOMEWORK HOUSE TO PROVIDE FIRST AID OR SEEK MEDICAL ATTENTION ON BEHALF OF MY CHILD.
AGREE WITH AUTHORIZED TO SEEK MEDICAL ATTENTION*:

–None–I AGREE with Medical Attention TextI DO NOT AGREE with Medical Attention Text

CHILD’S EDUCATION INFORMATION

Check box if the Child has an Individual Education Plan (IEP) or 504 through the school:  

Please describe any special services your child currently receives or ‘None’:

PERMISSION AND RELEASE

The tutoring program at Homework House is designed to provide tutoring free of charge, to children within  the community.

• The undersigned gives permission for child to be observed or interact with student interns and volunteers.
• The undersigned hereby holds harmless and releases Homework House,  its officers, staff members, and volunteers from any loss, liability, claim, suit or judgment that may arise out of or in connection with the undersigned making use of or participating in the free tutoring program.
• It is further understood and agreed that Homework House, its officers, staff  members, and volunteers are simply providing a free tutoring experience to children.  No claims or promises as to the child’s progress is intended or implied.  All children participating in the free tutoring program do so with the consent of their parents on a voluntary basis.

AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION

I give my permission to Homework House INC to contact my child’s school and share information with any and all school personnel. I further give my permission to Homework House INC to have the contact information of my child’s teachers (email and telephone number) and receive copies of any and all testing results, progress reports, report cards and Individualized Education Plans (IEP). I understand that the information shared between Homework House INC staff and school staff regarding academic progress will be kept confidential.

School*:    
Current Grade/Year*:–None–Pre-KK12345678

Teacher:  

I Agree with Permission and Release Statement Above*: –None–I AGREE with Release of Information TextI DO NOT AGREE with Release of Information Text

MEDIA/VirtuAL ONLINE TUTORING RELEASE

I hereby agree and give permission for Homework House Inc. to record, film, photograph, audiotape, or videotape my child’s name, image, likeness, spoken works, work performance, and movement in any form for the purpose of and in connection with any material that may be created by Homework House Inc. for promotional use.

I hereby further agree that Homework House Inc. is the sole owner of all the rights, title, and interest, including copyrights, and any other parts thereof for all purposes as Homework House Inc., shall determine in the sole discretion without limitations, reservation, or compensation to my child.

Images, likeness, spoken words, works, performances and movement in any form may be used for publicity, education, research, new releases, and public showings, but will not be used for commercial purposes.

By entering your name below, you are effectively providing your signature, indicating that all information on this form is true to the best of your knowledge and that you provide permission for your child to participate in Homework House Inc. Photos, Google Classrooms. Hangouts, Meet, Live, interactive Zoom sessions, Flip-Grid, TikTok, Instagram, Facebook, Twitter and Homework House Inc. produced YouTube videos. You also agree that you have read, understand and agree to the terms outlined above.

Virtual Programming Expectations Agreement

I understand that bullying will not be tolerated during Homework House Inc. of the virtual tutoring sessions or through Homework House Inc. virtual channels (YouTube). If my child participates in bullying behavior, s/he will be removed from participation in Homework House Inc. online programs immediately.

I understand that posting inappropriate pictures and/or videos of any sort is not acceptable online behavior. If my child posts inappropriately, s/he will be removed from participation in Homework House Inc. online programs immediately.

I understand that staff members of Homework House Inc. are mandated reporters and by law are obligated to report any suspected case of child abuse and/or neglect to the Department of Children and Families. We are required to cooperate fully in all investigations.

By checking the box below, you are indicating that you have read, understand and agree to the terms outlined above

I Agree with Media Release/Virtual Programming Expectations Text Above*: –None–I AGREE with Media Release TextI DO NOT AGREE with Media Release Text

Please double check the information you have provided.

Many of the above fields must be filled-in in order for the form to be accepted.  If any required fields are missing, the screen will be redisplayed with the missing field highlighted.  Please add that information and ‘Submit’ again.  If multiple fields that require information are blank, you may need to re-submit more than once.

Policy of Non-Discrimination

Homework House INC does not discriminate on the basis of race, gender, sexual orientation, religion, nationality or ethnic origin in the administration of its educational and admission policies.