Learning Khmer - Registration Form

Learning Khmer - Registration Form

Please fill out one form per person. Read through carefully and fill out the required areas.
Please note that the current fees for the year are as follows:
- Youth (7-14) - $125
- Adult (15+) - $200
THERE WILL BE NO REFUNDS, SO MAKE YOUR CLASSES COUNT.
Course Information
Youth Classes | IN PERSON SUNDAYS ONLY

Class times for Beginner course: 9:00 AM - 10:30 AM

Class times for Intermediate course: 10:45 AM - 12:15 PM

Adult Classes | REMOTE MONDAY AND WEDNESDAY NIGHTS ONLY

Class times for both Beginner and Intermediate courses will be from 6:00 PM - 7:30 PM. Link to Zoom will be given prior to start of class.
Which class are you registering for?*
Course Level*
Student Information
Student Name*

First NameLast Name
Birth Date*
MM/DD/YYYY
Gender*
Race
Ethnicity
EX: Cambodian, Puerto Rican, Haitian
Student's Full Address*
ex: 465 School St, Lowell, MA 01851
Student E-mail*
If you are a parent registering for your child, please put your email.
Mobile Number*
If you are a parent registering for your child, please put your mobile number.
Are you a returning student?*
If yes, please put the number of years you have learned. If no, type N/A.*
Individuals Under 18

If registrant is under 18 years of age, please fill out the entire Parent/Guardian portion of the form. If registrant is 18 years or older, please type "Adult" in all required sections if you would like to skip this portion.
Parent/Guardian Full Name*
Parent/Guardian E-Mail*
Parent/Guardian Mobile*
Relationship to Child*
Emergency Contact Information
Emergency Contact #1*
Relationship to Student
Mother, father, sister, brother, etc.
Emergency Contact #1 Email*
example@example.com
Emergency Contact #1 Mobile*
Please enter a valid phone number.
Emergency Contact #2
Relationship to Student
Mother, father, sister, brother, etc.
Emergency Contact #2 Email
example@example.com
Emergency Contact #2 Mobile
Please enter a valid phone number.
Do you have any medical condition, allergies, or medication we need to be aware of? If no, please type N/A.*
Electronic Signature Acknowledgement and Consent Form

I/We agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and all statements above are correct and true to the best of my/our knowledge.
Student's Full Name*
Date*

MonthDayYear
Date
Parent/Guardian's Full Name
ONLY IF STUDENT IS UNDER 18
Date

MonthDayYear
Date
If paying by card, please click on the link below.

Pay Online

To pay by cash or check, please meet with a CMAA staff.

We are located at:

465 School St
Lowell, MA 01851
978-454-6200
Should be Empty:

Learning Khmer - Registration Form

Course Information

Student Information

Individuals Under 18

Emergency Contact Information

Electronic Signature Acknowledgement and Consent Form