PhilaFLAM - Registration

PhilaFLAM - Registration

Please fill out this registration form. Information will remain strictly confidential and will only be used to determine which class your child may attend. We will confirm the registration as soon as possible.
I have read and accept the Privacy Policy*
Preferred school*
When would you like to start?

As soon as possibleNext school year
1st Parent or Guardian
Name*

First NameLast Name
Email*
example@example.com
Phone number*
Please enter a valid phone number.
What language does the 1st parent use with the child?*
2nd Parent or Guardian
Name

First NameLast Name
Email
example@example.com
Phone number
Please enter a valid phone number.
What language does the 2nd parent use with the child?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about PhilaFLAM?
We receive subsidies based on the number of children of French nationality. Please let us know if you or your child(ren) are French.

YesNo
I confirm that the child(ren) I want to register are francophone, understand and speak French.*

YesNo

Emergency information
Emergency phone number*
Please enter a valid phone number.
Authorized persons to pick up the student after school
1st parent Employer name*
2nd parent Employer name
In case of medical emergency involving my child, I understand every effort will be made to contact me and other emergency contact people whom I have provided. In any event, I hereby authorize PhilaFLAM, and each of their organizers, directors, members, employees, agents and volunteers to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. I hereby release PhilaFLAM from any liabilities arising out of any medical procedure described above, including but not limited to civil, criminal and financial responsibilities.*

YesNo

Registration confirmation
I agree to share my contact information for the directory and carpooling*

YesNo
Video/Photo: I hereby grant PhilaFLAM the right and permission to use photographs and/or video recordings of me and/or my child on PhilaFLAM.com and other websites and in publications, promotional flyers, educational materials, derivative works, included Internet, for educational, public relations or promotional purposes without compensation to me.*

YesNo
Current Date

MonthDayYear
Date
Registration fees
Your child(ren) will be tested for their French proficiency before being accepted in the program.

Registration and test fees are non refundable even if their level is deemed insufficient.

Payment Amount*

USDTotal including 1.9% + $0.30 processing fees

1st Parent or Guardian