NEW STUDENT REGISTRATION FORM
Please use Latin letters for all your inputs, except for the fields written in Bulgarian.

The purpose of this form is to register all your children in one input.
STUDENT INFORMATION
First, Middle and Last Name: *
Your answer
Име, презиме и фамилия на ученика *
(моля попълнете на кирилица)
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
ЕГН
Your answer
SSN
Your answer
Place of Birth: *
For those born in USA or Canada please add city and state (example: San Francisco, CA)
Your answer
Country of Birth: *
Desired Class Level: *
NOTE:
Final placment will be based on teacher evaluation and specific school requirements for age and level of understanding/speaking Bulgarian
Language Level: *
Language level (additional information)
Please describe in more details the language level of the child
Your answer
Desire date to begin *
MM
/
DD
/
YYYY
Student's Doctor Name:
Your answer
Doctor's Telephone:
Your answer
Insurance Company:
Your answer
Insurance ID #
Your answer
Plan/Policy #
Your answer
Explanations or comments about medical conditions that the school should be aware of:
Please list allergies and unusual conditions of which we should be aware of or any other special instructions:
Your answer
Second Sibling
Student First, Middle and Last Name:
Your answer
Име, презиме, фамилия на ученика
(моля попълнете на кирилица)
Your answer
Date of Birth:
MM
/
DD
/
YYYY
ЕГН
Your answer
SSN
Your answer
Place of Birth:
For USA born please add city and state (example: San Francisco, CA)
Your answer
Country of Birth:
Desired Class Level:
NOTE:
Final placment will be based on teacher evaluation and specific school requirements for age and level of understanding/speaking Bulgarian
Language Level:
Language level (additional information)
Please describe in more details the language level of the child
Your answer
Desire date to begin
MM
/
DD
/
YYYY
Student's Doctor Name:
Your answer
Doctor's Telephone:
Your answer
Insurance Company:
Your answer
Insurance ID #
Your answer
Plan/Policy #
Your answer
Explanations or comments about medical conditions that the school should be aware of:
Please list allergies and unusual conditions of which we should be aware of or any other special instructions:
Your answer
Third Sibling
Student First, Middle and Last Name:
Your answer
Име, презиме, фамилия на ученика
(моля попълнете на кирилица)
Your answer
Date of Birth:
MM
/
DD
/
YYYY
ЕГН
Your answer
SSN
Your answer
Place of Birth:
For USA born please add city and state (example: San Francisco, CA)
Your answer
Country of Birth:
Desired Class Level:
NOTE:
Final placment will be based on teacher evaluation and specific school requirements for age and level of understanding/speaking Bulgarian
Language Level:
Language level (additional information)
Please describe in more details the language level of the child
Your answer
Desire date to begin
MM
/
DD
/
YYYY
Student's Doctor Name:
Your answer
Doctor's Telephone:
Your answer
Insurance Company
Your answer
Insurance ID #
Your answer
Plan/Policy #
Your answer
Explanations or comments about medical conditions that the school should be aware of:
Please list allergies and unusual conditions of which we should be aware of or any other special instructions:
Your answer
PARENT/GUARDIAN INFORMATION
First and Last Name: *
Your answer
Relationship: *
Emergency Contact Phone: *
(XXX)XXX-XXXX
Your answer
Phone Type: *
Contact e-mail: *
NOTE: This e-mail address will be used for all messages, alerts and notifications sent by BCEC "Khan Asparuh"
Your answer
Address: *
Your answer
City *
Your answer
State *
ZIP: *
Your answer
SECOND PARENT/GUARDIAN INFORMATION
First and Last Name:
Your answer
Relationship:
Emergency Contact Phone:
(XXX)XXX-XXXX
Your answer
Phone Type:
Contact e-mail:
NOTE: This e-mail address will be used for all messages, alerts and notifications sent by BCEC "Khan Asparuh"
Your answer
Emergency Contact Information (different from parrents)
If parents cannot be reached in an emergency, please contact:
First and Last Name: *
Your answer
Relationship to Child(ren): *
Emergency Contact Phone: *
(XXX)XXX-XXXX
Your answer
Phone Type: *
Emergency Contact e-mail: *
Your answer
WAIVER:
AFTER SCHOOL EXTENSION PROGRAMS RELEASE OF LIABILITY Bulgarian Cultural and Educational Center (BCEC), Broenitsa LLC and all the agents including independent contractors and volunteers, do not maintain accident/injury insurance for students who may suffer injury or illness while participating in the after school program. Parents and guardians are encouraged to obtain their own insurance coverage.
I realize there are certain risks involved in participating in sports, games and/or any other activities of the BCEC and my child(ren) and I voluntarily assume those risks. These risks include, but are not limited to, minor or major bodily injury and possibly, the loss of personal property. I agree to inform my child(ren) that he/she must follow all program safety rules. I agree to hold harmless and indemnify the BCEC, Broenitsa LLC and all others associated with the center from all liability for any injury, which may be suffered by the individual registered in this class arising out of, or in any way connected with participation in this program. I understand that I will assume all risks of any injuries received.
I understand that the program provided by the BCEC has a specified end time. I am aware of that end time and understand that there is no adult supervision beyond the end time. I understand that it is my responsibility to pick my children on time. If my children are not picked up a BCEC may assign late pick-up fees and has the right to contact the police department and release my child(ren) into their custody.
I understand that the school is nut and meat free zone and agree not to bring such products at its territory.
By signing below I give BCEC, Broenitsa LLC and its agents, including management, independent contractors and volunteers, permission to photograph and videotape my child(ren) and use the prints and video in center displays, newsletters, brochures, and publish on YouTube, BCEC website and on school’s Facebook group. BCEC, Broenitsa LLC and its agents will never use names, address or any other personal information in these publications.
By clicking on the checkbox below, I hereby release and hold harmless the BCEC, Broenitsa LLC and its agents, including management, independent contractors and volunteers, from all liability for mishap, personal injury or property loss or damage while my children are engaged in the activities of the BCEC or walking home on their own.
I acknowledge and represent that I am over the age of 18, have read this entire document, that I understand its terms and provisions, and that I have signed it knowingly and voluntarily on behalf of myself and/or my minor children.
*
Required
For emergency treatment if it is deemed necessary by the school authorities and after all efforts to reach the parent or designated adult have failed. Your son/daughter will be taken by ambulance at parent’s expense to the nearest emergency facility.
*
Required
Additional information
Is there any other information about your child that you would like to share with us?
Your answer
Comments: (up to 300 characters)
Please use Latin letters to fill in.
Your answer
NOTE:
Registration is completed by submitting the registration form and paying $40 non-refundable registration fee per child.
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