Picture Perfect Participation Packet

Student Name:

Parent/Guardian Name:

Phone

Type of Services Provided:

In-Home Tutoring

In-Person Tutoring (outside the home)

Online Tutoring

Life Skills Camp

Consent and Agreement

Parent/Guardian Consent for Services

I give permission for my child to participate in tutoring services, camps, and/or social groups provided by Picture Perfect Learning Center. I understand and agree to the following terms:

Purpose

Services are designed to support my child’s academic growth, life skills development, and/or social-emotional learning based on their individual needs and the goals discussed.

Session Schedule

Sessions or group activities will be scheduled based on mutual availability or the program calendar. I agree to give at least 24 hours’ notice if we need to cancel or reschedule.

Confidentiality

Any personal, academic, or developmental information shared will remain confidential unless I provide written permission to share it with teachers, therapists, or other professionals involved in my child’s care.

Location of Services

Services may take place in-home, online, or at a designated location depending on the program selected. For in-home services, I will ensure a safe and distraction-free environment.

Learning Methods

I understand that various tools and strategies may be used to support my child’s learning, including visual aids, technology, hands-on activities, and interest-based methods.

Parental Involvement

I agree to maintain communication with Picture Perfect Learning Center staff and support my child’s learning or participation goals as needed outside of scheduled sessions.

Liability Waiver

I release Picture Perfect Learning Center and its service providers from any liability related to accidents, injuries, or losses that may occur during in-person, in-home, or group-based activities.

Media Release:

I give permission for photos or videos of my child to be used for educational or promotional purposes.

I do not give permission for any media use.

Parent/Guardian Name:

Parent/Guardian Signature:

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Emergency Care Information

Student Information

Full Name:

Date of Birth:

Month

Day

Year

Address

Allergies or Medical Conditions

Does your child have any known allergies or medical conditions?

No – My child has no known allergies or medical conditions.

Yes – Please list them below:

If yes, please list any allergies, medical conditions, or health concerns we should be aware of:

Is your child currently taking any prescribed medications?

No – My child is not currently taking any medication.

Yes – Please list below:

Medication Name | Dosage | Time Given | Special Instructions

Over-the-Counter Medication (e.g., Tylenol, Benadryl, etc.):

In case of minor pain, discomfort, or allergic reaction, do you give permission for Picture Perfect Learning Center staff to administer over-the-counter medications if needed?

Yes, I give permission to administer over-the-counter medications if necessary.

Yes, but please contact me before giving anything.

No, do not give my child any over-the-counter medication.

Additional Notes or Allergies to Any Medications:

Parent/Guardian Information

Parent/Guardian 1 Name:

Relationship to Student:

Phone Number (Cell):

Phone Number (Work):

Parent/Guardian 2 Name:

Relationship to Student:

Phone Number (Cell):

Phone Number (Work):

Emergency Contacts (Other than Parent/Guardian

These people have permission to pick up my child and be contacted in case of emergency.

Name:

Relationship to Student:

Phone

Name:

Relationship to Student:

Phone

Doctor & Insurance Information

Doctor’s Name:

Phone

Preferred Hospital:

Insurance Provider:

Policy Number:

Consent for Emergency Treatment

I authorize the staff of Picture Perfect Learning Center to obtain emergency medical treatment for my child if I cannot be reached.

Parent/Guardian Signature:

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919-332-0760

erika@pictureperfectlc.com