Payment Plan - Loma Portal After School Spanish Club
Mondays, Nov. 28, 2022 - Mar. 6, 2023 2:50pm - 3:50pm
Student's Name
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First Name
Last Name
Grade and Age
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Grade
Age
School Name
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Homeroom
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Language Proficiency Level
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Beginner
Intermediate
Advanced
Has your child enrolled in our programs before?
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Yes
No
Please describe area where your child needs most support with language learning.
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Special Instructions? IEPs (Please be specific), Allergies, etc.
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Parent Name
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First Name
Last Name
Parent Phone Number
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Please enter a valid phone number.
Parent E-mail
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example@example.com
Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone Number
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Additional person authorized to pick up my child
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Name
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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 - Loma Portal After School Spanish Club
Mondays, Nov. 28, 2022 - Mar. 6, 2023 2:50pm - 3:50pm. Payment plan consists of 3 bi-weekly payments of $98.34 for a total of $295.
$
98.34
Pay with Credit Card
Debit or Credit Card
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Last Name
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