Santa Barbara Tutoring & College Counseling Registration Form

SELECT CLASS THAT YOU ARE REGISTERING FOR

Tutoring (at any time of the year)

SAT 4-Day Prep Course | Feb 8, 22, 23 March 1

College Counseling 101 | Private Session

Student First Name *

Student Last Name *

Street Address ( include Apt No. ) *

City *

Zip Code *

First Name Parent / Legal Guardian *

Last Name Parent / Legal Guardian *

Cell Phone Number *

Home Phone Number *

Email Address *

Student's Birth Day *

Name of School Student Attends *

Grade *

Would you like to be added to our email list? *

Yes

No

How did you hear about us?

Name of Emergency Contact/Relationship *

Emergency Contact Cell/Home Phone Number *

Name of person/relationship authorized to pick up your child (other than parent/guardian) *

Cell Phone Number of person authorized to pick up your child *

Allergies (if none, type “none”) *

Additional information we may need to know

I Have read and fully understand this California Learning Center Waiver and Release. Please type today’s date: *

California Learning Center Waiver and Release PLEASE READ CAREFULLY BEFORE YOU COMPLETE AND SEND IN THIS REGISTRATION FORM THE UNDERSIGNED HEREBY RELEASES, WAIVES, AND AGREES TO INDEMNIFY AND HOLD HARMLESS The California Learning Center (CLC), its employees and owner from all liability to the undersigned, his or her personal representatives, (herein after referred to as releasees) officers, agents, or employees from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted. The Undersigned hereby grants to the CLC the right to take photographs of the participant, and authorizes the CLC, its assigns and transferees the right to copyright, use and publish the same in print and/or electronically. The undersigned agrees that the CLC may use such photographs for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. By clicking the SUBMIT button on this form you agree that you have read and fully understand the California Learning Center Waiver and Release.

Parent/Guardian Signature (Type your Name) *

Click SUBMIT button to send your information. Then, continue to the next section below to send us your payment.

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