Village Tutors Enumclaw + Black Diamond Tutoring

Note: Fields in red type or shaded red are required.

Student Information*

First:   Middle:   Last:   Nickname:
Street:   Address Line 2 (ie., Apt./POB):
City:   State:   Zip:
Home Phone (w/Area Code):  —OR—  Cell Phone (w/Area Code):
Student Email:

*Parents, if the student is a young child, please complete this section using the phone and email contact information of a Parent/Guardian. You may also View/Print the Enumclaw + Black Diamond Tutors Privacy Policy.

School Enrolled:

Grade Level:
  Grade History: (letter grade or G.P.A.)**
Student Requests Tutoring
in the Subject(s) of: 		Current
Term		 Last
Term		 2 Terms
Ago		 3 Terms
Ago
Math
Science
Language Arts
Social Studies
Foreign Language
  **Not required if school attended does not use a letter grade or
grade point system in assessing student performance.

Parent / Guardian (if Student is under 18 years of age)

First:   Middle:   Last:
Street:   Address Line 2 (ie., Apt./POB):
City:   State:   Zip:
Home Phone (w/Area Code):  —OR—  Cell Phone (w/Area Code):
Email Address:

Parent / Guardian (if Student is under 18 years of age)

First:   Middle:   Last:
Street:   Address Line 2 (ie., Apt./POB):
City:   State:   Zip:
Home Phone (w/Area Code):   Cell Phone (w/Area Code):
Email Address:

Emergency Contact

First:   Middle:   Last:
Home Phone (w/Area Code):  —OR—  Cell Phone (w/Area Code):
Relationship:

Photo Release

I  do /  DO NOT  voluntarily, with full understanding, under perjury, under laws of the State of Washington, grant the Enumclaw + Black Diamond Tutoring Program permission to photograph the student and/or parent or guardian named in this document and rights to use photos containing the image or likeness of named persons in displays and promotional materials including but not limited to posters, brochures, flyers, handouts, publications, web sites, and digital media. This document serves as a release for parent/guardian, child/ward, and all heirs, estate successes, and all members of family.
To protect the privacy of minors and student participants in the Enumclaw + Black Diamond Tutoring Program, students names or other personally identifying information shall NOT be published alongside any photo, likeness or reproduction.

Enumclaw + Black Diamond Tutoring Program

Code of Conduct

  • I understand that it is a privilege for me to participate in this program.
  • I understand that while I am at a tutoring drop-in center I am to be engaged in small group study, individual study or research, or engaged with a tutor.
  • I understand that every student and member of the staff is deserving of my respect.
  • I agree to conduct myself in a manner appropriate to a study environment.
  • I understand that if I am not conducting myself appropriately I will be asked to leave.
  • I understand that if I am asked to leave for a second time, I will not be allowed back for the remainder of that school term (either online or at the drop-in center).
  • I understand that the virtual campus is strictly for the use of tutoring and academic study. Any other use than this will be grounds for removal of my online privileges.
  • I understand that posting answers on the virtual campus for homework, tests or other academic endeavors is strictly prohibited and my result in my loss of online privileges.
  • I understand that the computer labs at the drop-in centers are strictly for academic work and research. Any use other than this is grounds for dismissal from the program.

Electronic Signature

By typing my name below and electronically submitting this form, I acknowledge my name as it appears on this document constitutes my signature, and I hereby agree to conform to the Enumclaw + Black Diamond Tutoring Program Code of Conduct on all occasions I participate in the program.

Student Signature:

Waiver, Release of Liability, Indemnification and Consent to Medical Attention

In exchange for my being allowed to participate in the Enumclaw + Black Diamond Tutoring Program (the "Program"), a program administered by Village Tutors, I, and my parent or legal guardian (individually and collectively referred to below in the first person singular) agree to be bound by each of the following:

  1. Voluntary Participation. I understand and confirm that my participation in the Program is voluntary.
  2. Identification of Risks. I understand that my participation in the Program may involve risk of injury and loss, both to person and to property. I also understand that the risk of injury may include the possibility of permanent disability and death. I understand that this Waiver and Release of Liability is intended to address all of the risks of any kind associated with my participation in any aspect of the Program, or with the time I am involved in the Program, including, particularly, such risks created by actions, inactions, or negligence on the part of Village Tutors or its directors, officers, employees, agents, volunteers, successors, or assigns, including but not limited to risks created by the following:

    1. the use and condition of various premises, facilities, and equipment;
    2. the lack or inadequacy of policies, rules, or regulations of the Program;
    3. the failure of FFA to foresee or to protect me from actions, inactions, negligence, recklessness, or intentional or criminal misconduct of persons, other than those affiliated with Village Tutors;
    4. the inadequacy or unavailability of medical facilities or treatment; or
    5. the lack or inadequacy of supervision.
  3. Assumption of Risk. I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my participation in the Program. I accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in the Program.
  4. Release and Waiver. I release Village Tutors and its directors, officers, employees, agents, volunteers, successors, and assigns from any and all liability for and waive any and all claims for injury, loss, or damage, including attorneys' fees, in any way connected with my participation in the Program (a "Claim"), whether or not caused in whole or part by the negligence or other misconduct of Village Tutors or any of the individuals mentioned above.
  5. Indemnification. I agree to indemnify and to hold harmless (in other words, to reimburse and to be responsible for) Village Tutors and its directors, officers, employees, agents, volunteers, successors, and assigns from all claims for any liability, injury, loss, damages, or expense, including attorneys' fees (including the cost of defending any Claim I might make, or that might be made on my behalf, that is released or waived by this instrument), in any way connected with or arising out of my participation in the Program, whether or not caused in whole or in part by the negligence or other misconduct of Village Tutors or any of the individuals mentioned above.
  6. Binding Effect. This instrument shall be binding upon my relatives, personal representatives, heirs, beneficiaries, next of kin, or assigns and shall inure to the benefit of Village Tutors and its successors and assigns.
  7. Consent to Medical Treatment. I authorize Village Tutors to provide to me, through medical personnel of its choice, customary medical assistance, transportation, and emergency medical services. This consent does not impose a duty upon Village Tutors to provide such assistance, transportation, or services.
  8. Severability. If any term or provision of this instrument or the application thereof to any person or circumstances shall to any extent or for any reason be invalid or unenforceable, the remainder of this instrument and the application of such term or provision to persons or circumstances other than those as to which it is held invalid or unenforceable shall not be affected thereby, and each term and provision of the instrument shall be valid and enforced to the fullest extent permitted by law.
  9. Applicable Law. Because Village Tutors and the Program are headquartered in the State of Washington, and in order to provide certainty in the law to be applied to the construction of this instrument, this instrument shall be governed, construed, and enforced in accordance with the law of the State of Washington.

THIS IS A WAIVER AND RELEASE OF LIABILITY. I HAVE READ THIS WAIVER, RELEASE OF LIABILITY, INDEMNIFICATION, AND CONSENT. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I AM SIGNING THIS WAIVER, RELEASE OF LIABILITY, INDEMNIFICATION, AND CONSENT VOLUNTARILY.

Student Electronic Signature

By typing my name below and electronically submitting this form, I acknowledge my name as it appears on this document constitutes my signature.

Student Signature (if 18 years or older):

Parent/Guardian(s) Electronic Signature and Authorization

Parent(s) or the legal guardian(s) must sign for a minor:

In exchange for my/our child or ward being allowed to participate in the Program, and as the parent(s) or legal guardian(s) of the above named individual, I/we verify that I/we fully understand, agree to, and accept all provisions of this Waiver, Release of Liability, Indemnification and Consent. Further, I/we hereby authorize Enumclaw + Black Diamond Tutoring Program and Village Tutors to contact my student's school to share information on this student's progress in tutoring sessions. Additionally, I/we authorize my student's school to share information regarding my student's past, present and future performance including classes taken and grades awarded. I understand and agree that Enumclaw + Black Diamond Tutoring Program and Village Tutors are NOT sponsored by the Enumclaw School District, and that the Enumclaw School District assumes no responsibility for the conduct or safety of the program/activity.

By typing my name below and electronically submitting this form, I acknowledge my name as it appears on this document constitutes my signature.

Parent/Guardian Signature:
Parent/Guardian Signature:

Demographic Questionnaire

The information gathered through this questionnaire is strictly for statistical purposes and will remain confidential. No personally identifying information will ever be associated with your responses.

Please indicate you  do /  DO NOT voluntarily submit the demographic information below.

I live: Inside City Limits   Outside City Limits   Outside King County   Unknown
 
Homeless: Yes   No
 
Single Parent/Adult Household: Yes   No
 
Annual Household Income:
under $20,200   $20,201 — $33,670  
$33,671 — $53,870   over $53,870
 
Student Age: 0-5 years   6-10 years   11-13 years   14-17 years   18 years+
 
Student Gender: Female   Male   Transgendered/Other
 
Student Disabilities: Yes   No
 
Student Race/Ethnicity:
American Indian or Alaska Native Asian, Asian-American
Black, African-American, Other African Hawaiian Native or Pacific Islander
Hispanic, Latino Multi-Racial
Other Non-White/Non-Caucasian White or Caucasian
 
Refugee/Immigrant: Yes   No
 
Limited-English Speaking: Yes   No
 
Military or Veterans' Child or Dependent: Yes   No