Playgroup Session Registration Form
Summer
Please choose Sessions (fee info here)
Please Select
June $75
July $60
Daily fee $20 (pay as you come if there is room in the class)
Select Days and Times
*
Thursdays 10am-10:50am ages 4-7
Thursdays 11:00-12:00pm ages 8-11
Mondays 10am-10:50am ages 4-7
Mondays 11am-12Pm ages 8-11
Other
Venmo
@jessicazepeda75
Student
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Additional Student
First Name
Last Name
Additional Student Date of Birth
-
Month
-
Day
Year
Date
Additional Student
First Name
Last Name
Additional Student Date of Birth
-
Month
-
Day
Year
Date
Allergies (per student)
*
Special Instructions (optional)
Exposure to Spanish (optional)
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
*
example@example.com
Emergency Contact Name (other than parent/guardian listed above)
*
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
*
I understand that there is no refund for being absent to a class.
*
I understand I will receive a refund if teacher is ill or for weather conditions (Spanish in Bloom will follow Canyons School District discretion).
*
I understand that there are no private make up class. However, my child can choose to attend another class their age if available.
Emergency Care
*
In the event of a medical emergency, I understand that every reasonable effort will be made to contact me at my number listed above. In the event I cannot be reached or if otherwise appropriate, I hereby give permission to Spanish in Bloom to secure treatment for the participant named above. I agree to pay all costs and expenses incurred in connection with such medical, dental or emergency services rendered to the participant.
Please Select
*
I give free permission to Spanish in Bloom and Jessica Zepeda to use my child’s pictures/videos on Social Media for the purpose of advertising/promoting Spanish in Bloom educational service.
I do not give permission to Spanish in Bloom/Jessica Zepeda to use my child’s pictures/videos on Social Media.
Signature
*
Venmo @jessicazepeda75
Please note: to ensure a spot in the class, both the registration and a payment must be completed. Thank you for understanding. Please contact (801)214-4454 for further questions.
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