Student Name
*
First Name
Last Name
If available, please provide the student's State Testing Number (STN)
Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Birthdate
*
Student Gender
Female
Male
Prefer not the answer
Student Race/Ethnicity
American Indian
Alaska Native
Asian
Black
Native Hawaiian or other Pacific Islander
White
Hispanic
Non-Hispanic
Current Grade
*
School District
*
Current Teacher
Does your child attend the after school program at your school?
Is your child eligible for Indiana Learns?
*
Please indicate which tutoring opportunity you are registering for (please choose only 1):
Keeping in mind that we may not be able accommodate all requests, please indicate your preference:
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Has your child been screened with characteristics of dyslexia or received a dyslexia diagnosis?
Does your child have an Individualized Education Plan (IEP) or 504 and receive special education services
Please list any academic, social or health needs we should be aware of:
Please list preferred tutoring days and times.
Parent/Guardian Name(s)
*
Parent/Guardian Contact Information (please provide phone numbers for each parent)
*
Parent/Guardian Email
*
I authorize the following people to transport my child to/from CAST Tutoring. In the event of an emergency if CAST cannot reach me CAST is authorized to contact and release information to the following people:
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Provide names and contact info for each emergency contact
Data Release: CAST needs to able to release and exchange student information with your child's school district and other tutoring partners in order to collaborate regarding specific learning needs. Specific information to be exchanged: any and all information pertaining to the student’s needs that will aid in assisting the reading specialist’s work with your student. Ex. STN, IEP/504 Plans, assessment data, etc.
*
This registration form is complete and accurate, and participant has permission to engage in all activities unless otherwise specified in writing. I understand that C.A.S.T. assumes no responsibility for injuries or illnesses which my child may sustain as a result of his/her participation in programming, the use of any equipment, facilities, exercises, or other activities. I expressly acknowledge that I assume the risk for any and all injuries and all illnesses which may result from his/her participation in these activities. I acknowledge that my child had been medically cleared to participate in vigorous physical activity. I also understand that there is a risk of injury while participating in physical activity by my child. I agree to hold harmless C.A.S.T. , its staff and volunteers for accidents or injuries arising out of his/her participation in the activity. In the event of a medical emergency, I understand that appropriate measures will be made to contact parents, guardians, and emergency contacts listed, however, give permission for C.A.S.T. to contact EMS on behalf of my child for treatment should the need arise. I understand that I assume the obligations that may arise from this event, should it occur. I also give permission to the personnel of C.A.S.T. and or local media to take photographs of my children to be used in marketing materials for C.A.S.T. I verify that I have the legal authority to speak on behalf go this minor, and assume responsibilities as stated above. I hereby consent for my child to participate in C.A.S.T. Tutoring programming:
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Parent/Guardian Electronic Signature:
