Student Intake Form
Student Information
Student Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
School
Current Grade
Back
Next
Parent/Guardian Information # 1
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Parent/Guardian Information # 2
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Best Way To Contact
What is the best way to contact your family?
Allergy Information
Please list any allergies your child may have, including food, environmental, or medication allergies. If there are no known allergies, please write "None."
Allergies:
Emergency Action Plan (if applicable):
Please note: If your child requires specific accommodations or medications for their allergies, kindly provide additional details.
Back
Next
Animal Consent
We would like to inform you that during your child’s tutoring sessions at our center, they may have the opportunity to interact with our friendly animals, including a bird, a tortoise, and several dogs and cats.
Please check the appropriate box below to let us know if you want your child around these animals during their time at Read With Leanne.
My child may be around the animals during their tutoring sessions.
I would prefer my child to be taught in an animal-free environment.
N/A (Virtual Clients)
Photo Consent
Please select one of the following options:
I give my consent for my child’s photograph to be taken during tutoring sessions at Read With Leanne and understand that these photos may be used for promotional purposes, including but not limited to the center’s website, social media, or printed materials. I also understand that all photos will be shared with parents for approval before posting or distribution.
I do not give my consent for my child’s photograph to be taken or used for any promotional purposes.
Parent Name
Date
-
Month
-
Day
Year
Date
Parent Signature
Submit
Should be Empty: