Consent Form

Student Information

Student Name *

Date of Birth *

Parent/Guardian Name *

Phone Number *

Email Address *

Grade *

Subject Area(s)

Start Date

Parent/Guardian Consent

I give permission for my child to participate in tutoring services with Positive Kids. I understand that the tutor may support my child with areas such as:

I give permission for my child to participate in tutoring services with Positive Kids. *

Student and Family Responsibilities

I understand that tutoring works best when the student attends regularly, participates actively, completes assigned work when needed, and has access to required school materials.

Parents or guardians may be asked to provide information such as report cards, teacher feedback, learning goals, assignments, or areas of concern to help the tutor support the student effectively.

I understand the student and family responsibilities described above. *

Communication Permission

Positive Kids may provide general updates to the parent or guardian regarding attendance, participation, progress, and areas requiring support.

Positive Kids will not communicate with the student’s school, teacher, doctor, therapist, or other professionals without parent or guardian consent, unless required by law or needed for safety.

Name/Organization

Purpose of Communication

Parent/Guardian Initials

Confidentiality

Positive Kids will respect the privacy of the student and family. Information shared during tutoring will be kept confidential, except when disclosure is required by law or necessary for safety.

Confidentiality may be broken if there is concern about:

Risk of harm to self or others
Abuse or neglect of a child
A legal requirement to release information
A serious safety concern requiring parent, guardian, or emergency involvement

I understand the confidentiality policy and limits described above. *

Attendance, Cancellations, and Limits of Service

I understand that consistent attendance is important for progress. I agree to follow Positive Kids’ cancellation, rescheduling, and payment policies as provided to me.

I understand that tutoring does not guarantee specific grades, report card results, school placement, or academic outcomes. Progress depends on several factors, including attendance, effort, school expectations, family support, and the student’s learning needs.

I understand the attendance and cancellation expectations. *

I understand the limits of tutoring services. *

Consent and Signatures

By signing below, I confirm that I understand the nature of tutoring services and give permission for my child to participate.

Parent/Guardian Name *

Parent/Guardian Signature *

Date *

Positive Kids Representative

Typing your name in the signature field confirms your consent electronically.

Consent Form for Tutoring Services

Before You Submit