Clone of English Class Registration Form (3p-5p)

English Class Registration

(3p-5p)
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Age
Which class is your child currently in at school?
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Which permit does your child currently hold?
* Please note that classes are offered for free only for refugee children. If space permits, we can consider other registrations at a reduced solidarity rate. *
Parent/Guardian Information
Name

First NameLast Name
Mobile Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does the child take any prescribed medications? If yes, please explain any instructions and provide the necessary quantity as needed.
Is there any personal information of which the organizers need to be aware?
Informed Consent and Acknowledgement

I hereby authorize my child to attend English language classes offered by the Refugee Welcome Center, an initiative of Emmanuel Episcopal Church of Geneva.

The classes will take place starting Thursday September 4, 2025 and every Thursday thereafter until Thursday June 25, 2026 (not including school holidays) as follows:

1) 3p-5p from 16.45h-17.45h

All classes take place at Emmanuel Church’s premises at 3 rue de Monthoux, 1201 Geneva.

The purpose of the classes is to introduce children to the English language in a fun and engaging way with a qualified English teacher from PEP English School. Emmanuel Church and PEP English School respect the diverse backgrounds of all students and ensure that its activities are secular in nature.

Classes are being offered free of charge for refugee children and will include the provision of a snack offered as of 16h on the 1st floor. Parents are welcome to wait for children on the 1st floor where coffee, tea and light refreshments are provided until 18h. Children are under the responsibility of their parents/responsible adult at all times during snack time.

No child is allowed to leave the premises on their own.

By registering my child, I commit to him/her attending all the classes. In the event of illness, I will contact the organizers in a timely manner. I understand that failure to regularly attend the classes without justified cause may result in the exclusion from the class and/or future activities offered.
Medical Release and Authorization

In the event of illness, injury or other emergency, I understand that every effort will be made to contact me. If time is of the essence, or if I cannot be reached, I hereby give the teacher or volunteers permission to act on my behalf to secure medical treatment as necessary, including, but not limited to: medical attentions, anesthesia, surgery and hospitalization, as the attending nurse or physician may prescribe. I understand that it is my responsibility to pay for any medical services which my child may receive while attending this event. I absolve and hold harmless the Fondation de la Chapelle d’Emmanuel, PEP English School and its designated volunteers and representatives from any liability in acting on my behalf in this regard.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Medical Insurance Information
Medical insurance company
Policy Number
Name of physician
Refugee Welcome Center contact information

In case of absence of the child or any other concerns, please contact Christine Aghazarm, 076 3956827, refugees@emmanuelchurch.ch
Data protection

This information is being collected solely for the purposes of the English classes and will not be retained after that time.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Should be Empty:

English Class Registration

Medical Insurance Information

Refugee Welcome Center contact information

Data protection