Payment Plan - Alcott Spanish Club
Wednesdays, Dec 7, 2022 - Feb 22, 2023, 12:50pm - 1:50pm
Student's Name
*
First Name
Last Name
Grade and Age
*
Grade
Age
School Name
*
Homeroom
*
Language Proficiency Level
*
Please Select
Beginner
Intermediate
Advanced
Has your child enrolled in our programs before?
Please Select
Yes
No
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 - Alcott After School Spanish Club
Wednesdays, Dec 7, 2022 - Feb 22, 2023, 12:50pm - 1:50pm. Payment plan consists of 3 bi-weekly payments of $98.34 for a total of $295.
$
98.34
for each
two weeks
Click to Pay
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