Summer camp Registration Form 2018

Student Information

Kid's Name *

First Name Last Name

This year our camps are limited to kids entering grade 1 to 6

Birth Date *

Month Day Year

School *

Entering Grade *

Gender *

Male Female

My child / children fluency in French

Beginner Intermediate Advanced Native

Is your kid registered in one of our afterschool or kids programs for 2018/2019 ? if yes, please precise.

Would you like to add another child ?

yes no

My child language for learning

French English both

My child / children fluency in French

Beginner Intermediate Advanced Native

Kid's Name *

First Name Last Name

Birth Date *

Month Day Year

Grade *

K 1 2 3 4 5

Gender *

Male Female

Choose your Session (s) (3 week each) : *

Session 1 : August 31 - September 18 Session 2 : September 21 - October 9 Session 3 : October 13 - October 30 Session 4 : November 2 - November 20 Session 5 : November 30 - December 18

Are you interested in : *

full time mornings only afternoons only

Are you interested in Aftercare 4:30 to 5:00 ?

yes no

Parent/Guardian Information

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

Authorized persons to pick up the child

Person 1 *

Prénom Nom de famille

Relationship to the child *

Phone Number *

Area Code Phone Number

Person 2

Prénom Nom de famille

Relationship to the child

Phone Number

Area Code Phone Number

Person 3

Prénom Nom de famille

Relationship to the child

Phone Number

Area Code Phone Number

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

I authorize my child’s picture to be used for the Alliance Française de San Francisco’s marketing opportunities with the understanding that my child’s name not be used. *

Yes No

Health Information

Please notify us of any change.

Insurance

Is the kid covered by family medical/hospital insurance ? *

yes no

Insurance Carrier

Group #

Policy #

Policy holder name

Relation ship to participant

Insurance

Does the camper have any allergy? *

no yes

Please precise allergies and treatment *

Does the camper 2 have any allergy? *

no yes

Please precise allergies and treatment *

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

French Learning Camp Registration 2020-2021