Xtudent Registration Form of Xpeed Fun Camp (Or Xpeed Tutoring Center) @ Global Elites Network Xpeed Learning Academy (xForm #xFC-123)
English: http://XpeedFun.Academy - 929-244-9955
Chinese: http://Chinese.XpeedFun.Academy - 929-260-2233
Registrar@XpeedFun.camp
Xpeed Fun Summer Camp Time: 9am ~6:pm, 7/5 ~ 8/26 Monday through Friday Weekdays for 8 weeks
Please follow the instruction carefully and fill in the form as thoroughly as possible. If you need help in translating English into Chinese, please call Xpeed Staff for help.
Pick a Site (If less than 30 students enrolled in a site, Xpeed might not open that site due to the cost and logistics issues.)
Xpeed Tutoring Center Program(s) Registered
Required
Student’s Full Name (First + Last)
Your answer
Grade Completed by Summer
Kindergarten
Grade 10+
Gender
Age
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Date of Birth (DOB)
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Mother’s Full Name (First + Last)
Your answer
Mother’s Daytime Phone #
Your answer
Mother’s Mobile Phone #
Your answer
Mother’s WeChat ID
Your answer
Father’s Full Name (First + Last)
Your answer
Father’s Daytime Phone #
Your answer
Father’s Mobile Phone #
Your answer
Father’s WeChat ID
Your answer
Address
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City
Your answer
State
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Zip
Your answer
Home Phone #
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Work Phone #
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Email:
Your answer
How did you find Xpeed Fun Summer Camp?
Required
Referral’s WeChat ID:
Your answer
Alternate Person to Notify in case of Emergency:
Please provide an emergency contact so that in case of emergency, Xpeed can have access to that person to solve your child's issue as quickly as possible.
Alternate Person's WeChat ID
Your answer
Alternate Person's Full Name (First + Last)
Your answer
Relation
Your answer
Alternate Person's Phone #
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Doctor’s Name
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Doctor’s Phone #
Your answer
Allergic to Medications, Food, etc…Please Explain:
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Pickup Requirement:
Only designated person(s) can pick your child up, even so, Xpeed needs to check on the photo and send for approval by parent or guardian.
Authorized Person 1
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Authorized Person 2
Your answer
Authorized Person 3
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Pickup Requirements by Xpeed Fun
A GeNXLA Parent Badge will be verified for pickup! Lunch and Snack Requirements: Parents have to pack kids’ daily lunch, 2 snacks and water at home and no food is shared in GeNXLA class. Parents have to clear kids’ medical immunization records before the first day the Xpeed Fun camp begins.
Total Tuition Payment: $
Your answer
Payment Type (For Credit Card or Paypal, A 3% Transfer Fee Will Apply)
Referral Discount %
Your answer
Online Registration?
Total Actual Amount $
Your answer
Release Form (To be completed by parent or guardian)
In the event of emergency requiring medical attention, I hereby grant permission to a physician or hospital personnel designated by GeNXLA to attend my son or daughter. I expect every effort will be made to contact me in order to receive my specific authorization before any hospitalization.
Parent or Guardian’s Signature
Your answer
Child’s Full Name (First + Last)
Your answer
Emergency Phone #
Your answer
Health Insurance Name & Policy #
Your answer
Xpeed Fun Camp Description
The 2016 Xpeed Fun Summer Camp only hosts K-12 students for an age group between 5 to 18 years old. One whole year in public or private school kindergarten program has been prerequisite for any pupil to enroll in the 2015 Xpeed Fun summer program. GeNXLA uses technology and quality private one-on-one tutoring system to make students learn far faster, deeper and more than ever before. Every student at the Xpeed Fun summer camp can have access to hundreds of world-class best interactive learning apps and paper books. The 2015 Xpeed Fun camp has three concentrations: math, reading and science. For math, Xpeed will work to students' potential if students have been preparing at least six months ahead in memorizing the 12x12 times table. For reading, the Xpeed Fun camp focuses on helping students rapidly build up a large vocabulary by using special learning technology. Then with enough words, students can speed up their reading dramatically. The Xpeed Fun procedures will help students associate words in many dimensions so that they can memorize words much longer. And the reading dose will reach a few millions of words in total, depending on each child’s current reading level. For science, students get exposure on many subjects like Chemistry, Physics, Computer, etc.
Prerequsite Requriements for student before attending the Xpeed Fun camp:
PHOTOGRAPHY, VIDEO, REPORTS AND PROMOTIONAL RELEASE
I do hereby acknowledge and authorize Xpeed Fun Camp (or Xpeed Tutoring Center) and Global Elites Network Xpeed Learning Academy to take and use photographs, videos, reports and written comments of or by my child for promotional and informational materials. Further, I agree to release and discharge Global Elites Network Xpeed Learning Academy and its sponsors from any and all liability in connection with the use of such photographs, videos, reports and written comments of or by my child.
Student's Full Cooperation Guarantee by both Student and Parent
To work your child to his/her potential, student's full cooperation is a must. And parents should encourage the child to follow the Xpeed Learning Procedures strictly instead of discouraging the child by quitting in the middle. If student didn't follow Xpeed Tutors' instruction, even the best learning methodology couldn't be able to get the best learning outcome.
Student's Signature in Full Cooperation with Xpeed Tutors
Your answer
Parent's Signature in Encouraging the Child's Full Cooperation with Xpeed Tutors
Your answer
Remark
* 2016 Xpeed Fun Summer Camp: July 5 to August 26 weekdays from 9:00am to 6:00pm except for holidays (July 4th)
* 2015 Xpeed Fun Summer Camp in 6 towns: White Plains, Flushing, Manhattan, Brooklyn, Livingston, Princeton
* To protect your kids’ privacy, please fill in this secured form and send the photos only to the above Email box only.
Please make sure you have completed and return ALL of the following forms in order to complete the registration process by the Xpeed Fun Registrar Office:
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