Private Lessons Application & Waiver Form - Korean American Center Language Program
Only ONE registration form PER student. 

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First Name *
Last Name *
Korean Name (if applicable) *
Address: Street *
City *
State *
Zip *
Email *
Phone number *
Time Zone *
Are You 18 Years or Older? *
If NOT, Birthdate
If in school, Grade
Emergency Contact Person and Phone Number (minors must enter parent/guardian contact) *
Previous Korean Language Experience (formal or informal)
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If Yes, please briefly explain
Day and Time Frame You Are Available For Initial Lesson (select all that apply). Final schedule will be determined by you and the instructor
6AM - 8AM PST
8AM- 10AM PST
10AM - 12PM PST
12PM - 3PM PST
3PM - 5PM PST
5PM - 7PM PST
7PM - 9PM PST
Not Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How Did You Hear About Us? *
Required
Please Read Carefully •  Each package must be used within 30 days of purchase.•  All packages must be completed within 90 days. No exceptions will be made AFTER The 90 days. Any exceptions will only be made prior to the 90 days (ex: planned vacation, business travel, etc) and will require Director’s approval. •  NO REFUNDS, NO CREDITS, NO TRANSFERS •  Packages may be purchased for another student, but packages are non-transferable once used. • Lessons under 60 minutes will still be charged the full hour. *
 24 hours notice for any scheduled cancellations. Cancellations less than that will be considered used. *
Korean American Center                1. Refund and Credit Policy: Once the class has been paid, there will be no refund or credit. Credit may be given under special circumstances and at the sole discretion of Korean American Center                                                          2. Attendance and Absences: In order to respect other students, we ask that you please show up on time. No credits or make up will be given for absences.                                                                              3. I agree to hold the Korean American Center   harmless from any and all claims, loss or damage to my personal property, liabilities and costs, including attorney’s fees, as a result of my participation in this program and any other activities sponsored by Korean American Center  , including travel to and from any activity (including this class).                   4. I hereby grant Korean American Center   the right to use and reproduce any and all photographs, video clips, and/or audio clips in conjunction with your involvement at Korean American Center   in any organization newsletters, brochures, web sites, flyers and publications, or any outside school approved publications such as newspaper, magazines, web sites promoting our language program and organization.                                                 5. I will not hold Korean American Center  , its host facility or any of its regular personnel and volunteer workers liable for injury, accidents, illness or other thing unexpected occurring during class hours and other Korean American Center   activities. In case of medical emergency, Korean American Center  personnel on duty have my permission to obtain emergency treatment for myself. I have read and understand the forgoing statements. I agree to assume the full responsibility stated above and waive all claims as indicated.                                                        6. I hereby waive and release any and all rights and claims I may have against Korean American Center  with their respective Board Members, administrators and teachers for any and all injuries which maybe suffered by me in connection with my participation and attendance or on the premises of Korean American Center  .   I have read and agree to policies of Korean American Center   Language Program.         *
FOR STUDENTS UNDER 18 YEARS OLD:  I am the parent or legal guardian of the Participant. I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing Korean American Center   from all liability on my and the students behalf, (b) waiving my and the students’ right to sue Korean American Center  . In case of medical emergency, the school personnel on duty have my permission to obtain emergency treatment for my child until I can be contacted. I have read and understand the forgoing statements. I agree to assume the full responsibility stated above and waive all claims as indicated.
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Parent's Name
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