Emergency Contact Form

Mission:

Through engaged and interactive learning, Back to the Basics Tutoring LLC aims to help increase the knowledge of basic foundational concepts

Vision:

Back to the Basics Tutoring LLC aims to inspire and motivate children to excel academically through engaged and interactive learning by using new approaches to increase their focus and participation in a learning environment. To help develop the children's needs and also build a partnership with parents, families, and communities to best help the children to build their progress and confidence in identified academic areas.

CHILD'S INFORMATION

Child's Name

Nickname

Birthday

Address

Phone

PARENT/GUARDIAN CONTACT INFORMATION

First/Last Name

Work Address

Work Phone

Home Phone

Cell Phone

Include your email address and Facebook names (For communication only)

Facebook

First/Last Name

Work Address

Work Phone

Home Phone

Cell Phone

Include your email address and Facebook names (For communication only)

Facebook

RELEASE INFORMATION

I give authorization to release my child in the event I am unavailable OR if I consent to:

First/Last Name

Address

Relationship to Child

Home Phone

Cell Phone

Facebook

First/Last Name

Address

Relationship to Child

Home Phone

Cell Phone

Facebook

MY CHILD'S DOCTOR CONTACT INFORMATION

Name

Speciality (e.g., pediatrics)

Address

Phone

OTHER IMPORTANT INFORMATION:

I grant permission for Back to the Basics Tutoring LLC, including but not limited to its volunteers, affiliates, members, or associates to provide or arrange for medical treatment and/or transportation to an evacuation site and/or medical facility for my child, identified above, during an emergency or disaster. I also grant permission for my child to be released to any of the emergency contacts I have designated on the previous page if I am unable to pick them up in an emergency or any other time. I agree to not hold Back to the Basics Tutoring LLC, its affiliates, partners, sponsors, volunteers, directors,associates or members liable for any harm, medical needs, food allergies or illness that occurs while in or outside of the program.

Your Signature

Today's Date

Thanks for submitting!

Additional Questions?

Contact Kiyana Mensah

Phone: 414-973-1009

Email: Bck2thebasicstutoring18@gmail.com

If you would prefer, you may download the application below and email the completed document to bck2thebasicstutoring18@gmail.com

Download Document