Bilingual Kids registration

Lifetime Montessori After School Spanish Club - Payment Plan

Wednesdays, January 11, 2023 to February 15, 2023 3pm - 4:15pm
Student's Name*

First NameLast Name
Grade and Age*

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

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

NamePhone 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 - Lifetime Montessori After School Spanish ClubPayment Plan for Lifetime Montessori After School Spanish Club - Wednesdays, Jan 11 to Feb 15, 3pm - 4:15pm. Payment plan details: $70 reoccurring bi-weekly payments for 3 payments and a total of $210.
$70.00 for each two weeks

Total

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Lifetime Montessori After School Spanish Club - Payment Plan