Mes Amis French School Private Tutoring Program Registration Private Tutoring Program Registration Form: Student Name * First Name Last Name Age * Sex * Male Female Non-binary Prefer not to respond Date of Birth * MM DD YYYY Schooling * Toddlers/Preschool Elementary Education (Grades K-6) Secondary Education (Grades 7-12) Level * 1 2 3 4 Child Resides With * Both parents/legal guardians Parent / Legal Guardian #1 Parent / Legal Guardian #2 Other Payment Options * Check Credit Card PayPal Venmo Zelle Contact Information Parent / Legal Guardian #1 Name * First Name Last Name Relationship to Child * Parent / Legal Guardian #1 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent / Legal Guardian #1 Phone * (###) ### #### Parent / Legal Guardian #1 Email * Parent / Legal Guardian #1 Employer & Occupation * Parent / Legal Guardian #1 Employer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent / Legal Guardian #1 Work Phone * (###) ### #### Parent / Legal Guardian #1 Work Email * Can we contact Parent / Legal Guardian #1 at work? * Yes No Parent / Legal Guardian #2 Name * First Name Last Name Relationship to Child * Parent / Legal Guardian #2 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent / Legal Guardian #2 Phone * (###) ### #### Parent / Legal Guardian #2 Email * Parent / Legal Guardian #2 Employer & Occupation * Parent / Legal Guardian #2 Employer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent / Legal Guardian #2 Work Phone * (###) ### #### Parent / Legal Guardian #2 Work Email * Can we contact Parent / Legal Guardian #2 at work? * Yes No Emergency Contact / Authorized Pick Up #1 * Note: Contact cannot be parent listed above First Name Last Name Emergency #1 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency #1 Phone * (###) ### #### Emergency #1 Relationship * Emergency Contact / Authorized Pick Up #2 * Note: Contact cannot be parent listed above First Name Last Name Emergency #2 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency #2 Phone * (###) ### #### Emergency #2 Relationship * Medical Information Student's Physician * Physician's Street Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Physician's Phone * (###) ### #### Student's Dentist * Dentist's Street Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Dentist's Phone * (###) ### #### Known Allergies/Illnesses Food Restrictions Medications Regularly Taken Other Significant Medical Information Thank you for completing your Registration Form! We will be in touch about your Private Tutoring Program Registration. Mes Amis Permission Statements: Student's Name * First Name Last Name 1) Emergency Measures * I give permission to the staff of Mes Amis to take whatever emergency measures (including medical or surgical care) are judged necessary for the care and protection of my child while under the supervision of the school. Yes No 2) Emergency Measures * I understand that in some emergency situations Mes Amis will need to contact the Emergency Medical Service (911) before the parent, child’s physician, or other adult who it acting on the parent’s behalf. In the event of a non-life threatening medical emergency, my child should be transported to _________________ Hospital. If it is a life threatening medical emergency, I understand that my child will be transported to Methodist Hospital which is closest to Mes Amis. My child will be transported at my expense. I understand 2a) Emergency Measures * Hospital Name 3) Waiver * In consideration of your acceptance of my child as a student at Mes Amis French School, or St. David’s Episcopal Church I hereby waive, release, indemnify, and agree to hold harmless Mes Amis French School, LLC its employees, and agents, from any claim arising out of any and all injuries suffered by my child incidental to or connected with any activity sponsored by Mes Amis French School, LLC. I agree 4) Photography Permission * I give Mes Amis permission to use photographs or video of my child for publication in school materials at the discretion of Mes Amis French School. Yes No 5) Poison Control * I give my permission for a Mes Amis director or qualified teacher to help my child to follow up including the administration of medication under the instruction of Poison Control. Yes No 6) Non-Prescription Medications * I give my permission for a staff member of Mes Amis to apply Non-Prescription Medications (lotions, Vaseline, sunscreen, lip balm, wet wipes, baby wipes) according to the manufacturer’s directions on my child. I understand that this is not an ordinary procedure and, if necessary, should be applied before coming to school. Yes No 7) Insect Repellant * I give my permission for a staff member of Mes Amis to apply insect repellant lotion according to the manufacturer’s directions on my child. I understand that this is not an ordinary procedure and, if necessary, should be applied before coming to school. Yes No 8) Field Trips * I give my child permission in the field trips included in the activities for which they are registered. Yes No 9) School Directory * I give Mes Amis French School permission to be in the school’s directory. (The information in this directory is not for sales opportunities or for any other use than for sharing information that would benefit the students of Mes Amis. It will be shared with families who registered with the school, and is not to be shared with other entities. The directory will be sent via email periodically, as updates are made). Yes No 10) Signature * Email * Phone * (###) ### #### Thank you for submitting your Permission Statements!
