2017 - 2018 DSSV registration form
Enrollment at the beginning of the school year
• Age: The school accepts children of age 5 till 18 and children of age 4 who will turn 5 before September 1st 2017. Parents of children who will turn 5 after September 1st 2017, please contact us at info@dutchschoolsiliconvalley.org
• Dutch language skills assessment: New students are language assessed on an individual basis by the directeur (principal) of the school during a family interview at your home. Interviews with new students enrolling at the beginning of the school year are taking place during the summer vacation. Dutch language skills are a deciding factor in the acceptance and placement of your child at the DSSV (Dutch School Silicon Valley)
• Enrollment fee: There is a one-time only non-refundable enrollment fee of $100 (per new family).This fee is waived for returning families or expanding/changing family enrollment.

Enrollment during the school year is possible, but limited.

Registration and emergency information
We'd hereby like to register our child (children) for the 2017 - 2018 schoolyear of the Dutch School Silicon Valley
Last name *
Your answer
Street address *
Your answer
City *
Your answer
Zipcode *
Your answer
First name child 1 *
Your answer
Age child 1 (as of September 2017) *
Your answer
Date of birth child 1 *
(month/day/year)
Your answer
Grade child 1 (as of September 2017) *
Your answer
Allergies (including the use and availability of epi-pens) / other important medical information child 1 *
Your answer
Learning challenges / disabilities child 1 *
Your answer
IEP (Individual Education Plan) / 504-plan / handelingsplan child 1 *
Your answer
First name child 2
Your answer
Age child 2 (as of September 1st 2017)
Your answer
Date of birth child 2
(month/day/year)
Your answer
Grade child 2 (as of September 1st 2017)
Your answer
Allergies (including the use and availability of epi-pens) / other important medical information child 2
Your answer
Learning challenges / disabilities child 2
Your answer
IEP (Individual Education Plan) / 504-plan / handelingsplan child 2
Your answer
First name child 3
Your answer
Age child 3 (as of September 1st 2017)
Your answer
Date of birth child 3
(month/day/year)
Your answer
Grade child 3 (as of September 1st 2017)
Your answer
Allergies (including the use and availability of epi-pens) / other important medical information child 3
Your answer
Learning challenges / disabilities child 3
Your answer
IEP (Individual Education Plan) / 504-plan / handelingsplan child 3
Your answer
In case of a major emergency your child can only be released to:
First and last name of father/mother (or male/female guardian) *
Your answer
Address, city and zipcode of father/mother (or male/female guardian) *
(if different from above - otherwise fill in same as above)
Your answer
Daytime phone number of father/mother (or male/female guardian) *
Your answer
Cell phone number of father/mother (or male/female guardian) *
Your answer
Email address of father/mother (or male/female guardian) *
Your answer
First and last name of (other) father/mother (or male/female guardian) *
Your answer
Address, city and zipcode of (other) father/mother (or male/female guardian) *
(if different from above - otherwise fill in same as above)
Your answer
Daytime phone number of (other) father/mother (or male/female guardian) *
Your answer
Cell phone number of (other) father/mother (or male/female guardian) *
Your answer
Email address of (other) father/mother (or male/female guardian) *
Your answer
My child / my children have received all vaccines (or immunizations) obligated for his/her/their age/ages *
At all times the Dutch School Silicon Valley (the “School”), and its board members, directors, officers, administrators, staff (a.o. teachers and teaching assistants), employees, volunteers and agents, are authorized to take any measures necessary for the protection of my child(ren) during the hours of the 2017 - 2018 DSSV classes and events.
Initials *
Your answer
Objectives
English speaking families
Dutch speaking families
Comments :
Your answer
Permission to Use Photographs and Student (art) Work
During the course of the academic year, the Dutch School Silicon Valley may wish to place photographs of class and school activities (in which DSSV students and/or DSSV families participate), in the DSSV newspapers (only emailed out to then current DSSV families, staff and board members), on the DSSV website (http://http://www.dutchschoolsiliconvalley.org) , or on the DSSV Facebook page (http://www.facebook.com/dutchschool). The DSSV website and Facebook page are public and not password protected.

DSSV may also wish to put DSSV student (art)work in the DSSV newspapers, on the website or on the Facebook page.

In accordance with school policy, no names of individuals will be released with any photographs or any student (art) work

We consent to the use of photos of my child/children/other family members taken during class or school activities *
(No names will be released with any photos)
Yes, we consent
No, we do NOT consent
in the DSSV newspapers
on the DSSV Facebook page
on the DSSV website
We consent to the use of DSSV student (art) work made during class or school activities *
(No names will be released with any student (art) work
Yes, we consent
No, we do NOT consent
in the DSSV newspapers
on the DSSV Facebook page
on the DSSV website
Initials *
Your answer
Waive and release
The undersigned (the “Signer”), being the parent(s) and/or legal guardian(s) of the minor child(ren) (the “Child”) named at the beginning of this form , for valuable and sufficient consideration, receipt of which is hereby acknowledged, on behalf of themselves and the Child do hereby knowingly and intentionally fully and irrevocably release, to the full extent permitted by California law, the Dutch School Silicon Valley (the “School”), and its board members, directors, officers, sponsors, administrators, staff (a.o. teachers and teaching assistants), employees, volunteers and agents, from any and all claims or liability, known or unknown, of any kind whatsoever, which may now exist, or at any time in the future arise, with regard to any matters relating, directly or indirectly, to the Child’s enrollment or attendance at the School, or to the Signer’s or the Child’s participation in any activities directly or indirectly related to, or sponsored or sanctioned by, the School, regardless of whether or not said activities occur on School premises or elsewhere. By our initials below and by our signatures at the end of this form, we knowingly waive and release any and all legal claims that we or the child(ren) may now or in the future have against the School, or anyone connected with it.
Initials *
Your answer
Class schedule / time slots
We strive towards scheduling students with the same age (grade), language skills, and background in the same time slot. Making the best possible schedule is quite a challenge. Your co-operation/flexibility is appreciated.

To give an indication, please find below the timeslots of last schoolyear (2016-2017):

• Berkeley

Tuesday afternoon - 4 PM till 6.30 PM
Wednesday afternoon - 4 PM till 6.30 PM

• San Francisco

Thursday afternoon - 3.45 PM till 6.15 PM

• San Jose

Tuesday afternoon - 4 PM till 6.30 PM.

• Palo Alto

Tuesday afternoon - 3.45 PM till 6.15 PM
Wednesday afternoon - 3.45 PM till 6.15 PM
Thursday afternoon - 3.45 PM till 6.15 PM
Saturday morning - 10 AM till 12.30 PM

The above schedule is subject to change from schoolyear to schoolyear.

Please tell us which location you would like to register your child for : *
Required
Which day of the week has your preference? *
Which other day(s) would work as well? * *
* We’ll use this information to explore possible day changes or to add a day/timeslot to our schedule.
Required
Which day does NOT work? *
Required
Please indicate which priority the Dutch lessons have *
Payment
For new families, there is a one-time non-refundable enrollment fee of $ 100 (per family). This fee is waived for returning families or expanding/changing family enrollment.

The regular tuition for the 2017 - 2018 schoolyear will be $145 per month per child. There also is an additional obligatory event-contribution of $30 per child.

Discount policy
• For families with 3 children enrolled in our program, we offer a 50% discount on the tuition of the third child.

Our payment portal accepts automatic bank to bank transfers (ACH), creditcards, PayPal and checks. You will receive an invoice and detailed payment advise from our treasurer. If you have any questions or special requirements please contact our treasurer at penningmeester@dutchschoolsiliconvalley.org

Initials *
Your answer
Cancellation
Admittance to the school takes place for the duration of the entire school year. When cancelling, a written notice has to be given 30 days (a month) in advance by emailing the director and board of the school (wieneke@dutchschoolsiliconvalley.org + bestuur@dutchschoolsiliconvalley.org).

Initials *
Your answer
To the best of our knowledge, all the information filled in on this registration form is true and complete. We have read the requirements and are fully committed to complying with them. We understand that payment of the required fees must be made by the payment deadlines outlined. Our signatures below affirm all of the above.
Signature of father/mother (or male/female guardian) *
Your answer
Signature of (other) father/mother (or male/female guardian) *
Your answer
Filling in this form is done at your own risk.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms