Bilingual Kids registration

Juarez Elementary After School Spanish Club - Payment Plan

Tuesdays, October 18 to December 6, 3:40pm - 4:40pm
Student's Name *

First Name Last Name
Grade and Age *

Grade Age
School Name *
Homeroom *
Language Proficiency Level *
Has your child enrolled in our programs before? *
Please describe area where your child needs most support with language learning. *
Special Instructions? IEPs (Please be specific), Allergies, etc.. *
Parent Name *

First Name Last Name
Parent Phone Number *
Please enter a valid phone number.
Parent E-mail *
example@example.com
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *
Please enter a valid phone number.
Additional person authorized to pick up my child *

Name Phone number
How did you hear about us? *
Photo/Video Release *

I hereby allow Bilingual Kids to use my child's picture, face, or likeness in advertising for the sole purpose of promoting the Bilingual Kids program. I understand this could mean print, online, or video images of in-program activities.
Parent/Guardian Consent *

I hereby release Bilingual Kids from any and all liability arising out of my child's participation in this program. I assume all risks associated with this activity. In case of illness/injury, I authorize a representative of Bilingual Kids to obtain immediate medical treatment for my child. I will not hold Bilingual Kids responsible for any billing or payment related to emergency medical care.
Parent/Guardian Signature *

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Payment Plan - Juarez Elementary After School Spanish Club Payment Plan for Juarez Elementary After School Spanish Club - Tuesdays, Oct 18 to Dec 6, 3:40pm - 4:40pm. Payment plan details: $70 reoccurring bi-weekly payment for 3 payments total.
$ 70.00 for each two weeks
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Juarez Elementary After School Spanish Club - Payment Plan