Math Tutoring Registration

Parent/Guardian First Name: Parent/Guardian Last Name: Parent Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix Parent/Guardian Phone: Parent/Guardian Email: What math subject/topic do you need help with? What is the household income where the student resides? (This question links to grant funding) Below $30,000 $30,001 - $45,000 $45,001 - $60,000 $60,001 - $75,000 $75,001 - $90,000 $90,001+ Number of Attendees: Student First and Last Name Student's Date of Birth Is the student a participant of: Central College Talent Search Links-NSBE Jr. Chapter Big Brothers Big Sisters Neither Sister to Sister / Brother to Brother How did you hear about Jewels Academy? PHOTOGRAPH CONSENT WAIVER:I understand that Jewels Academy may photograph my child individually or in a group setting. I understand that photos may be used in brochures, websites, newspapers, presentations, and television spots to further publicize the mission of the organization. I give full consent for these and similar uses of my child's photographic likeness, waiving any liability for Jewels Academy's Y.E.S. or its directors or employees. Choose YES for consent to take pictures or No to exclude your child from any pictures. If you have a coupon, please enter code here (case-sensitive):