After-School Tutoring Student Application

Name *
Name
Date *
Date
Date of Birth *
Date of Birth
Grade (2016-2017 School Year) *
ex. Mother/Father
ex. 123 Mockingbird Lane, Richmond, VA 23223
Home Phone Number
Home Phone Number
Cell Phone Number
Cell Phone Number
ex. Mother/Father
ex. 123 Mockingbird Lane, Richmond, VA 23223
Home Phone Number
Home Phone Number
Cell Phone Number
Cell Phone Number
I give Church Hill Activities and Tutoring, Inc. permission to access my child's school records including, but not limited to, their quarter, semester, and yearly grades, attendance records, and health forms; a student's records may be accessed in order to gauge program success, to provide incentives for student achievement, and to better equip volunteers working with your child.
Your name here will serve as an electronic signature.
Date *
Date
I, being the parent and/or legal guardian of my child, do hereby authorize my child to participate in any and all activities held by church hill activities and tutoring, inc., a Virginia nonprofit organization ("CHAT"). Such activities include but are not limited to the following: tutoring, mentoring, Bible studies, life-skills training, arts and crafts, musical training, community service activities, and also a series of summer exploration trips that include but are not limited to outdoor camping, Paramount's Kings Dominion, Virginia Beach, supervised pool parties, Metro Richmond Zoo, etc.
Having authorized my child to participate in CHAT, I further agree as follows:
(1) I will not hold CHAT liable for and hereby release any and all claims that I or my child may have as a result of my child's participation in the above-stated activities;
(2) I understand that most of CHAT's activities will occur at the house of one of the homeowners in the Church Hill neighborhood listed below (each a "homeowner"). I hereby agree that my child has permission to attend the CHAT activities at the following locations and I further agree not to hold any homeowner liable for and hereby release any and all claims that I or my child may have for any liability against the homeowner that results as a part of my child's involvement in CHAT:
chat properties, llc 601 N. 31st St Richmond, VA 23223
chat properties, llc 3015 N St Richmond, VA 23223
Murray and Lauren Withrow 1309 N. 20th St Richmond, VA 23223
Matt and Emiline Lyell 2906 Q St Richmond, VA 23223
Percy and Angie Strickland 706 Chimborazo Blvd Richmond, VA 23223
Bethlehem Baptist Church 1920 Fairmount Ave Richmond, VA 23223
Carlisle Ave Baptist Church 2010 Carlisle Ave Richmond, VA 23223
Percy and Angie Strickland 1130 N. 28th St Richmond, VA 23223
(3) I grant permission for any photographs and videos taken of my child participating in CHAT activities to be included on CHAT's website and in its promotional materials. • In the event I wish to revoke any part of the permission granted hereunder or cancel any part of this agreement, I agree that I will provide a notice of such revocation in writing to Mr. Percy Strickland [address listed above] and that the provisions of this agreement shall remain in effect until the receipt of such written notification by Mr. Percy Strickland. • This agreement, and the interpretation hereof, shall be governed exclusively by its terms and by the law of the Commonwealth of Virginia, without reference to its choice of law provisions. • This agreement sets forth all of the promises, agreements, conditions, and understandings between the parties respecting the subject matter hereof and supersedes all prior negotiations, conversations, discussions, correspondence, memoranda, and agreements between the parties concerning such subject matter.
Date *
Date