Online Language Class Registration Form

Les Puces Hybrid Course
The book, project, worksheets, progress card and stickers are sent to you in the post and you access our members-only online portal to complete the two month module.
Your Details

Your first pack is just about ready, but we need to take a few pieces of information about you and your child, so we can get your book and project to the right place and let you access the online material.

All information provided on this form will be transferred onto our secure database, and will not be shared with any other company - in line with GDPR regulations.

If you have any questions about this form, please contact me at bonjour@lespuces.co.uk
Your First Name *
Your Last Name *
Mobile Number *
Please enter your mobile number, inc. country code.
E-mail *

Confirmation Email Please enter and confirm your email address.

Number of Children *
How many children are attending?
Language
Do you require us to print out the worksheets for you, at a cost of £3 per child?

Yes No
Base Cost
Base cost in GBP. See calculation for French
Additional Child Cost
Cost per additional child in GBP
Excess postage charge
Hidden field for holding postage for international customers.
Total cost per block
Total cost per block of classes
Don't worry! You will get a £13 discount off your Trial Pack. We will email you at the end of your trial to see if you would like to continue. You are not signing up for payment now. You will be sent a separate invoice.

First Child Details
Child's First Name *
Child's Last Name *
Child's Date of Birth *

Day Month Year
Child's Date of Birth

Day Month Year
Child's Gender *

Boy Girl Undisclosed
Can we have permission to use photos or videos of this child in our marketing or promotional material? *

Yes No
Does this child have any allergies as we may send out treats in with the language packs? *

Yes No
Please describe any allergies, chronic illness, or medical conditions?

Second Child Details
Child's First Name *
Child's Last Name *
Child's Date of Birth *

Day Month Year
Child's Date of Birth

Day Month Year
Child's Gender *

Boy Girl Undisclosed
Can we have permission to use photos or videos of this child in our marketing or promotional material? *

Yes No
Does this child have any allergies as we may send out treats in with the language packs? *

Yes No
Please describe any allergies, chronic illness, or medical conditions?

Third Child Details
Child's First Name *
Child's Last Name *
Child's Date of Birth *

Day Month Year
Child's Date Of Birth

Day Month Year
Child's Gender *

Boy Girl Undisclosed
Can we have permission to use photos or videos of this child in our marketing or promotional material? *

Yes No
Does this child have any allergies as we may send out treats in with the language packs? *

Yes No
Please describe any allergies, chronic illness, or medical conditions?

Fourth Child Details
Child's First Name *
Child's Last Name *
Child's Date of Birth *

Day Month Year
Child's Date Of Birth

Day Month Year
Child's Gender *

Boy Girl Undisclosed
Can we have permission to use photos or videos of this child in our marketing or promotional material? *

Yes No
Does this child have any allergies as we may send out treats in with the language packs? *

Yes No
Please describe any allergies, chronic illness, or medical conditions?

Fifth Child Details
Child's First Name *
Child's Last Name *
Child's Date of Birth *

Day Month Year
Child's Date Of Birth

Day Month Year
Child's Gender *

Boy Girl Undisclosed
Can we have permission to use photos or videos of this child in our marketing or promotional material? *

Yes No
Does this child have any allergies as we may send out treats in with the language packs? *

Yes No
Please describe any allergies, chronic illness, or medical conditions?

Online Module

Unlocked when you join up
Do you want to receive our newsletter? *

Yes No
Where did you hear of us?
e.,g. Website, Instagram, Facebook
Terms & Conditions

As Parent and/or Guardian of the children, I hereby agree to the terms and conditions as set out on the following page Terms & Conditions
Confirmation

BY SUBMITTING THIS FORM I HEREBY INDICATE THAT I AM ACCEPTING THE TERMS & CONDITIONS AS DESCRIBED ABOVE.
Should be Empty:

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Les Puces Hybrid Course