2017 Summer Clubs Registration Form
Welcome to Fun Chinese Program 2017 Summer Clubs! Please submit a separate registration form for each child you are registering and note 10% family discounts are available.
Child's First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Grade completed as of June 2017
If your kid's is under 5 years old, please leave this field blank.
Your answer
Language Use at Home *
Your answer
Years of Learning Chinese (if any)
Your answer
Please list the names of this student’s siblings that will be attending the course.
name(s)
Your answer
Address *
Your answer
Phone Number *
Your answer
E-mail Address *
Your answer
Parents'/Guardians' Names *
Your answer
Other numbers where parents/guardians may be reached (work, cell, etc.):
Your answer
ALTERNATIVE CONTACT - for emergency and you cannot be contacted:
Name/Relationship; Phone Number(s)
Your answer
ALLERGIES: (Please write "none" if no allergies) *
Your answer
MEDICATIONS (List below, with doses and times): (Please write "none" if child does not take any medication.) *
Your answer
MEDICAL CONDITIONS including ADHD or any other behavioral conditions within the last 3 years. (Please write "none" if no medical conditions exist.): *
Your answer
Physician name and number *
Your answer
Insurance name and policy *
Your answer
Permission Form *
I give my permission for the student(s) above to take part in the Fun Chinese Program 2017 Summer Clubs. This child, to the best of my knowledge, is in good physical condition and is capable of attending the course. I understand that indoor and outdoor activities have an inherent risk factor, and that all appropriate precautions will be taken for the safety of my child. I give my permission to the staff members, teachers, and volunteers and/or hospital staff to administer proper medical assistance to the above named participant. I agree not to hold the Fun Chinese program or any of their agents responsible in the event of injury to my child.
Signature of Parent or Guardian (Please Type) and Date *
Your answer
Please check all options that apply to you: *
Required
Total *
We only accept cash in person. Please make sure to write your student(s)' name(s) on the envelope. If you have registered a full day club, please bring your own lunch.
Your answer
Tuition Refund Policy: Prior to the beginning of the term through the second week, 100 percent of tuition can be refunded. After the end of the third week of classes, no refunds are offered.
Classroom Location: 9508 Great Hills Trail, Austin, TX 78759
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