Student's Name

First Name

Last Name

Pod Organizers Name

First Name

Last Name

Days of the Week Class Held

Monday

Tuesday

Wednesday

Thursday

Friday

Time class begins

Hour

Minute

Second

AM PM

Time class ends

Hour

Minute

Second

AM PM

Parent's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Phone

(###)

###

####

Person(s) to be contacted in case parents cannot be reached:

First Name

Last Name

Phone 1

(###)

###

####

Expiration

MM

DD

YYYY

Card Holder Name

First Name

Last Name

Card Holder Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I understand that my payment is non-refundable, unless a course is cancelled. Additionally, I understand that Developing Minds does not provide refunds or make-up sessions for missed classes, not previously scheduled with Developing Minds. I understand that my class rate will be based on the number of students in my class (as prearranged with Developing Minds).

I have read and agree with the Developing Minds payment terms.

I hereby release Developing Minds LLC and Laurie Stern from any liability resulting from my child’s participation. In the event of a medical emergency, Developing Minds may authorize medical transportation / and or treatment for my child.

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that Developing Minds has put in place preventative measures including temperature checks, COVID-19 screening measures, social distancing, and mandatory mask-wearing to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Developing Minds can not guarantee that my child will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Developing Minds, the tutor, the students and their families.

I voluntarily seek services provided by Developing Minds and acknowledge that I must comply with all set procedures to reduce the spread while my child is receiving tutoring.

I hereby release and agree to hold Developing Minds harmless from, and waive on behalf of myself, my child, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Developing Minds, or that may otherwise arise in any way in connection with any services received from Developing Minds. I understand that this release discharges Developing Minds from any liability or claim that I, my child, my heirs, or any personal representatives may have against Developing Minds with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Developing Minds. This liability waiver and release extends to the hosting family together with all owners, partners, and employees.