Registration Form

Please complete this form for each student enrolling in tutoring services. The information provided helps ensure the safety, well-being, and personalized support of each scholar.

Student Name

First Name

Last Name

Date of Birth

YYYY

Current Grade Level

Gender

Male

Female

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Phone Number (optional)

You may provide your student’s phone number if you would like them to be able to ask questions or share art progress in between sessions. This communication will take place over group chat with you included.

(###)

###

####

Primary Parent/Guardian Name

First Name

Last Name

Primary Guardian Phone Number

(###)

###

####

Primary Guardian Email Address

Secondary Parent/Guardian Name

First Name

Last Name

Secondary Guardian Phone Number

(###)

###

####

Secondary Guardian Email Address

Emergency Contact 1

First Name

Last Name

Phone

(###)

###

####

Emergency Contact 2

First Name

Last Name

Phone

(###)

###

####

Pickup Authorization (In-Person Tutoring Only)

List adults authorized to pick up student.

First Name

Last Name

Relationship

First Name

Last Name

Relationship

Password for Pickup Change

If you need to authorize someone not already listed above to pick up your child, you must notify us in writing via text or email. Your message must include the pre-determined password listed below. Verbal authorizations over the phone will not be accepted.

Medical Concerns/Alerts

Please note if the student has allergies, asthma, IEP, etc.

Favorite snacks (if applicable)

Do you give permission for me to provide snacks on occasion? (In-person only)

Current School

Current Teacher

First Name

Last Name

Current Art Teacher

First Name

Last Name

Is there a particular high school or art college/university you are seeking admission to?

Anything else we should know to support your scholar:

Photo/Video Permission

I understand that photos or short video clips of my child may be taken during sessions for instructional purposes, progress tracking, or marketing. These will be shared with me (parent/guardian) for review. Photos/videos will not be used publicly without my written consent.

Yes, I agree

No, I do not agree

Guardian Signature

By filling in my full name on the box below, I confirm that the information provided on this registration form is complete and correct.

First Name

Last Name

Date

YYYY

Registration Form

Rachel Neikirk, Meshi LLC