Phone: 904-637-4720

Tutoring Registration

BRIGHT MINDS TUTORING REGISTRATION FORM

FOR GRADES: K-12
PLACE: A pre-determined place set by the parent and BMYD.
COST: Affordable cost will vary depending on package - discounts apply. (money order or credit card accepted, no cash)
REGISTRATION FEE (NON-REFUNDABLE): $40.00 per student.
PAYMENT SCHEDULE: Session fees are due prior to tutoring services being rendered.
Programs: Reading, Writing, Math, Social Studies, Science, FCAT, EOC, ACT, SAT, College Prep, PERT and much more...

Personal Information: To be completed and electronically signed by the student's parent/guardian. If you don't have a credit or debit card you can send a money order for the tutor cost and registration fee to the following address: Bright Minds Youth Development • P.O. Box 441963, Jacksonville, FL 32222

PLEASE NOTE: ALL FIELDS WITH AN ASTERISK (*) ARE REQUIRED.

Student Name*: Age*: Date of birth*:

2015-16 Grade level*: School*:

Graduation Year*:

Academic Subjects student needs help*:

Student Name: Age: Date of birth:

2015-16 Grade level: School:

Graduation Year:

Academic Subjects student needs help:

Student Address*:

City*: State*: Zip*:

Parent Email 1*:

Parent Email 2:

Mother Name*:

Cell*: ()

Home*: ()

Father Name*:

Cell*: ()

Home*: ()

Please list two people who are authorized to pickup your child (must be over 18 years old):

1st Authorized Person's Name: Age:

Relation to child:

2nd Authorized Person's Name: Age:

Relation to child:

I authorize BMYD to contact and coordinate with my child’s teacher and to use the internet supervised for school purposes?* YesNo

Best day(s) for tutoring?* MTUWTHURFRISATSUN

Best time(s) for tutoring?*

PLEASE NOTE: if you schedule a session and do not cancel within 24 hours of the session, the fee will be NON-REFUNDABLE.

I have read and I fully accept the terms and conditions concerning Bright Minds Youth Development, Inc. (BMYD). tutoring program. I understand that I am volunteering to enroll my child in BMYD tutoring program and understand that by doing so does not guarantee any positive results in my child’s reading, grades or test scores. I understand that this is also a release of Liability, Waiver of all possible claims and assumption of risk, made by me, the undersigned Releaser, on my behalf and on the behalf of my child (if Releaser is under 18 years of age), to BMYD Tutoring and its individuals participating in tutoring sessions offered by this organization. I hereby agree as follows: To waive any and all claims that I have or may, in the future, have against BMYD Tutoring and its volunteers, its directors, officers, tutors and representatives (all of whom are hereinafter collectively referred to as Releasees) To release the Releasees from any and all liability for any loss damage, injury or expense that I or my child may suffer as a result of my participation in this tutoring program, due to any cause whatsoever, including negligence. All decisions made by me are my own, and the Releasees will not be responsible for any consequences arising from these decisions. To hold harmless and indemnify the Releasees from any and all liability for any consequences that may result from my reliance on information given through the tutoring service. This agreement shall be binding upon my heirs, next of kin, executors, administrators, assigns and representatives. This release is intended to cover all matters of injury, damage or loss, (be they tort, contract or otherwise) whether known, unknown, foreseeable, unforeseen, patent, latent, regarding injury abuse or damage to property or person.. I freely accept and fully assume all risk, dangers, hazards, and the possibility of personal injury, death, property, damage or loss resulting from my participation in this tutoring program. I agree to abide by the tutoring policies set by BMYD. I understand that program policies are subject to change at BMYD tutoring discretion and understand that if I do not abide by these policies, this may result in the disqualification and removal of my participation in the tutoring program.

Parent/Legal Guardian Signature*:

Date*:

(By entering your name, you agree to accept the terms of the above document with an electronic signature.)

(Once you have completed the registration form on this site and hit submit, the Tutor Director will reach out to you and discuss the specific needs you have and go over our programs in detail. When tutoring packages are selected and confirmed the office administration will provide you a username and password to review and pay the invoice.)