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+) - $175
THERE WILL BE NO REFUNDS, SO MAKE YOUR CLASSES COUNT.
Course Information
Class times for Beginner course: 9:00 AM - 10:30 AM

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

Instructors: Tararith Kho and Chhenghak Chhoeung
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
Emergency Contact #1 Email*
example@example.com
Emergency Contact #1 Mobile*
Please enter a valid phone number.
Emergency Contact #2
Relationship to Student
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
Should be Empty:

Learning Khmer - Registration Form

Course Information

Student Information

Individuals Under 18

Emergency Contact Information

Electronic Signature Acknowledgement and Consent Form