SATURDAY LANGUAGE FUN DAY
Spanish, Mandarin, or ESL - Saturdays, December 3, 10 & 17, 10am-12pm
Student's Name
*
First Name
Last Name
Grade and Age
*
Grade
Age
School Name
*
Language of choice
*
Please Select
Spanish
Mandarin
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..
*
How did you hear about us?
*
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
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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Saturday, Dec 3, 2022 10am-12pm
$
40.00
Saturday, Dec 10, 2022 10am-12pm
$
40.00
Saturday, Dec 17, 2022 10am-12pm
$
40.00
Full Month of December 10am-12pm
$
110.00
Payment Methods
Debit or 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.
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