Bilingual Kids registration

Longfellow Homework Club

Wednesdays, Nov 30, 2022 - Feb 15, 2023, 1pm - 2pm and/or 2pm - 3pm
Student's Name*

First Name Last Name
Grade and Age*

Grade Age
School Name*
Homeroom*
Language Proficiency Level*
Select Program Times*

Full Program (two hours): Wednesdays, Nov 30, 2022 - Feb 15, 2023, 1pm - 3pm $4951st Hour: Wednesdays, Nov 30, 2022 - Feb 15, 2023, 1pm - 2pm $2952nd Hour: Wednesdays, Nov 30, 2022 - Feb 15, 2023, 2pm - 3pm $295
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*

Clear

My Products*

Full Program (Two Hours) Homework ClubWednesdays, Nov 30, 2022 - Feb 15, 2023, 1pm - 3pm

$495.00

1st Hour Homework ClubWednesdays, Nov 30, 2022 - Feb 15, 2023, 1pm - 2pm

$295.00

2nd Hour Homework ClubWednesdays, Nov 30, 2022 - Feb 15, 2023, 2pm - 3pm

$295.00

Enter coupon

Total

$0.00

Pay with Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Longfellow Homework Club