Bainbridge Chinese Culture & Arts
Youth Private Lesson Registration Form
Class Type/Fee (please select one) *
Required
Student Information
Name of Student (First/Last) *
Your answer
Age/Grade/School *
Your answer
Medical Condition or Allergy *
Your answer
Address *
Your answer
Parent(s) Information
Name of Parent(s)/Guardian(s) *
Your answer
Phone (Home/Mobile) *
Your answer
Email *
Your answer
Doctor and Emergency Contact Info
Emergency Contact (Name/Phone) *
Your answer
Family Physician (Name/Phone) *
Your answer
Medical Disclaimer
As the parent or legal guardian of the above named student, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. I hereby authorize Bainbridge Chinese Culture & Arts and its staffs to act on my behalf in accordance with their best judgment in any emergency requiring medical attention. I hereby waive and release Bainbridge Chinese Culture & Arts, its board members and its staffs from any and all liabilities for any injuries or illness incurred by my child while participating in Bainbridge Chinese Culture & Arts activities.
*
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Print Name (Parent) and Date *
Your answer
Thank You For Registering
Please click "Submit" button below to complete the registration, and notify the administrator for class arrangement and faster service.

Please contact us at admin@bainbridgechinese.org or (206) 486-0826 if you have any questions.

Bainbridge Chinese Culture & Arts
P.O. Box 11681
Bainbridge Island, WA 98110
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