Emergency Contact Form & Waivers

To complete your registration, please fill out the form below with your child's/children's information.
Child Information

If you are registering multiple children
there is room provided below for up to three children.
Child's School *
Child's First Name *

First Name Last Name
Child's DOB (MM/DD/YYYY) *
Child's Sex *
Child Has The Following Allergies *
Class Purchased *
IMPORTANT: If you don't remember the class you purchased please check your email inbox for your receipt.
Continue below to register a second or third child
If your child is in two classes or Class + Summer Camp,
please select the 2nd class or camp from the "class purchased" option below.
Child's School
Child's Name
Child's DOB (MM/DD/YYYY)
Child's Sex
Child Has The Following Allergies
Class Purchased
IMPORTANT: If you don't remember the class you purchased please check your email inbox for your receipt.
Child's School
2nd Child's Name
2nd Child's DOB (MM/DD/YYYY)
Child's Sex
Child Has The Following Allergies
IMPORTANT: If you don't remember the class you purchased please check your email inbox for your receipt.

Emergency Contact
Father's Name *
Cellphone *
Include Area Code
Work Phone
Include Area Code
Email *
example@example.com

Address (If different from main address)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Name *
Cellphone *
Include Area Code
Work Phone
Include Area Code
Email *
example@example.com

Address (If different from main address)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

EC #1: Name *
EC #1: Phone Number *
Include Area Code
EC #1: Relationship To Child *
EC #2: Name
EC #2: Phone Number
Include Area Code
EC #2: Relationship To Child

Physician & Dentist Emergency Contact
Physician *
Physician Phone Number *
Include Area Code
Physician Medical Plan Number
Dentist *
Dentist Phone Number *
Include Area Code
Dentist Medical Plan Number

Authorized People To Take Child From Facility
Authorized Person #1 to pick up child. *
Authorized Person #1 Phone *
Include Area Code
Authorized Person #1 Relationship To Child *
Authorized Person #2 to pick up child.
Authorized Person #2 Phone
Include Area Code
Authorized Person #2 Relationship To Child
EC: Signature of Parent (Please Type) *
EC: Date *

- Month - Day Year
Date

Acknowledgment,
Medical Consent, Waiver and Release
Acknowledgment *

I, parent or legal guardian of the above student and a minor, hereby acknowledge that I have registered my child to attend “Spanish in Action School of Language for Children Inc.” at 3001 N. Sepulveda Boulevard, Suite “G”, Manhattan Beach, CA 90266. While my child is attending class at Spanish in Action School of Language for Children Inc. during any class in any calendar year, including before and after class when my child is in the custody of the school, I hereby authorize Maria Ure and the Spanish in Action employees, teachers, assistants or other authorized representatives, to act in my absence as my agent to consent to medical examination and/or treatment for my child. I hereby further release Maria Ure, Spanish in Action Inc., and their employees, teachers, assistants and representatives, and further waive any and all claims and causes of action, known and unknown, arising out of or in connection with Spanish in Action language classes, failure to follow drop off/ pick up routine rules, any and all activities undertaken during the time my child is attending class, or under the supervision of Maria Ure or the Spanish in Action Inc. employees, teachers, assistants and representatives, including driving my child as may be required in case of an emergency or in case no parent, guardian or authorized person shows up to pick up my child and my child needs to be returned to my home address.
Parent Signature (Please Type) *

Permission To Take Pictures
Permission To Take Pictures *

I hereby give permission for images of my child captured during Spanish in Action year round classes and camps through video, photo and digital camera to be used solely for the purposes of Spanish in Action promotional materials and publications. I understand that the photos and videos may be used on flyers and on the Spanish in Action website, youtube and social media in an effort to create awareness about the Spanish program for children and waive any rights of compensation or ownership thereto.
*

Yes No
Can we tag you on Facebook and Instagram when your child is on one of our a videos or picture? *

Yes No
Your name on Facebook is...
Your @ name on Instagram is...
How did you hear about Spanish In Action? *
Comments
Date *

- Month - Day Year
Date
Picture Parent/Guardian Signature: (Please Type) *
Should be Empty: