Tutor and Education Consultant Program Information Form

Primary Information:   *First Name: *Last Name: *E-mail Address: *Daytime Phone: Evening Phone: Best Time to Call: Address (Street): Address (Street 2): City: State: ZIP:     Please answer the following: Number of years experience in the field: Do you have ownership in any other type of business? Yes No Do you have employees? No Yes - If yes please check the box if the following statement is true: I utilize a written employment application. I have a written procedure for reporting and tracking claim/incident information. I display posters required by state and federal law for items such as anti-discrimination or wage, etc. I anticipate layoffs in the next 6 months. I conduct performance evaluations of all employees. I have an employee handbook. I have reason to believe I may have an employment practices liability claim. Have you ever had or have reason to believe you may have in the future a claim for Employment practices liability, Employee benefits liability or Educators errors and omissions. No Yes, please indicate circumstances: Do you provide any certification or accreditation activities? Yes No   Do you publish any materials other than a school newspaper or promotional materials? If so, please provide samples. Yes No Do you have a contract that the parent/student must sign? Yes No