Student Registration & Intake Form

Student Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Age

Gender

Daytime School & Current Grade

Student Status

Portuguese spoken at home?

Student language background

Academic goals

Other

Previous Portuguese instruction

Socio (Member)#

Primary Contact Name

First NameLast Name

Relationship to Student

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Secondary Contact Name

First NameLast Name

Relationship to Student

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Emergency Contact Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Allergies / Dietary Restrictions

Medical Conditions / Learning Needs

Payment Preference

Preferred Payment Method

Permission to participate in Escola Lusitânia activities at the Portuguese Club of Long Branch

Media release permission for photos/videos of the child to be used on official school media (social media, website, event flyers)

Parent/Guardian Signature

Date

Student Registration & Intake Form

Student Information

Language Background

Parent / Guardian Information

Emergency Contact & Health Information

Tuition Payment Preference

Parent Authorization & Media Release