Do you accept the risk and consent to services? *

Yes

No

Do you, your child, or anyone you have recently been in contact with have any of the following symptoms? Fever (defined as above 100.4° F degrees), Chills, Cough, Sore Throat, Shortness of breath and/or trouble breathing, Persistent pain, pressure or tightness in the chest, new loss of taste or smell? *

Yes

No

Have you or others accompanying you to today’s appointment traveled outside of our local area or outside of the US within the past 14 days? *

Yes

No

Have you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

Yes

No

I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s appointment to a later date. *

Yes

No

WEEKLY TUTORING/SPEECH CLIENTS: I understand that if at any time my health, my child's health, or the health of those that we have come in contact with has changed at any time; it will be my responsibility to immediately inform True Potential Education. At that time I will reschedule or move my appointments to a virtual format as long as necessary, under the guidance of state and federal regulations. *

Yes

No

N/A - I do not currently have on-going tutoring/speech sessions scheduled at TPE.

Student/Client *

First Name

Last Name

Parent/Guardian *

Type "NA" if you are a client age 18+

First Name

Last Name