After School Program Enrollment Form

Museum After School Spanish Program Registration Form
Please complete and submit one form per student being enrolled in theSpanish Program.
Parent's Name*

First NameLast Name
Parent's Phone Number*

Area CodePhone Number
Parent's Email*
Student's Name*

First NameLast Name
Student's Age*
Gender

FemaleMale
Level of Experience with Foreign Language*

BeginnerIntermediateAdvanced
Grade:*
Please describe the area where your child needs most support with language learning.
Language of Choice*

SpanishMandarinESL
Special instructions? (IEP's, Allergies, etc.) Please be as specific as possible.*
Please specify each person, including the name of parents, who has permission to pick up your child from the After School Program.
Authorized Person to Pick Up:*

First NameLast Name
Authorized Person to Pick Up:

First NameLast Name
Phone #*
Emergency Contact Person:*

First NameLast Name
Phone #*
How did you hear about us?*
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 that this would be on print, online, and/or video images of in-program activities.*

YesNo
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, I authorize a representative of Bilingual Kids to obtain immediate care deemed necessary by licensed medical personnel. I have read and fully understand these terms and I sign it voluntarily.*

I Agree
Signature*

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Museum After School Spanish Program Registration Form