Student Registration

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Student Information

Student First Name(Required)

Student Last Name(Required)

District(Required)

School(Required)

Grade(Required)

Other District

Gender(Required)

Male

Female

DOB(Required)

Month

Day

Year

Program(Required)

Jump Into Math

Jump Into English

Does the student currently attend the school provided After School Program?(Required)

Yes

Does the student currently receive any Special Education services? (Speech, Academic Support, Counseling, etc.)(Required)

Yes

If Yes, please provide details regarding the student’s special education services, accommodations, and/or school site health plan

Parent/Guardian Information

Student lives with...(Required)

Both Parents

Mother

Father

Guardian

Other

Parent/Guardian 1

First Name(Required)

Last Name(Required)

Email Address

Cell Phone(Required)

Work Phone

Preferred language

English

Spanish

Other

Other Language

Parent/Guardian 2

First Name(Required)

Last Name(Required)

Email Address

Cell Phone(Required)

Work Phone

Preferred language

English

Spanish

Other

Other Language

Medical Condition(s) / Allergies

Are there any additional medical condition(s) / allergies that we should be aware of?(Required)

If Yes, Please Explain.(Required)

Local Emergency Contact(s)

First Name(Required)

Last Name(Required)

Relationship(Required)

Phone(Required)

First Name(Required)

Last Name(Required)

Relationship(Required)

Phone(Required)

First Name

Relationship

Phone

After Tutoring

My student will be picked up from tutoring by someone on this form (Parent, Guardian and/or Emergency Contact)(Required)

Yes

My student will be dismissed by JIM Enterprises to the school provided After School Program(Required)

Yes

My student will walk home from tutoring. I release all liability from JIM Enterprises.(Required)

Yes

If other, please explain.

Authorizations & Notifications

Emergency Authorization: I authorize JIM Enterprises to seek emergency medical care for my student if needed. Staff will contact the person listed on this form so that my student may be picked up promptly(Required)

Yes

Photo Release: I give permission for my student to be photographed or recorded during program activities. These images may be used by JIM Enterprises for educational, promotional, or informational purposes in print or digital formats.(Required)

Yes

Program Communication Notification: By enrolling, you consent to receive automated text messages from JIM Enterprises with program updates. Message and data rates may apply. Reply STOP to unsubscribe anytime. Your contact information will be kept confidential.

Additional Student Information

Please provide any additional information that would help us provide your student with the best support.

By signing below, I acknowledge that the information provided is accurate and that I have read and understand the authorizations and notifications in this form.

Signature(Required)

November 10, 2025

Student Information

Parent/Guardian Information

Medical Condition(s) / Allergies

Local Emergency Contact(s)

After Tutoring

Authorizations & Notifications

Additional Student Information

Email:

Phone: