After School Program Enrollment 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

Level of Experience with Foreign Language

Gender

Grade:

Please describe the area where your child needs most support with language learning.

Please specify each person, including the name of parents, who has permission to pick up your child from the After School Program.

Special instructions? (IEP's, Allergies, etc.) Please be as specific as possible.

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.

Signature

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.

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Golden Hill After School Spanish Club Registration Form

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