The World LANGUAGE HOUSE
Registration Form 2011-12

 
FOR WHICH CLASS(ES) ARE YOU REGISTERING? (Please be specific.) 
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ON WHAT DAY & AT WHAT TIME IS/ARE THE CLASS(es)? 
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Do you want your MIDDLE/HIGH SCHOOL STUDENT to receive a LETTER GRADE for this CLASS(ES)?          YES         NO
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STUDENT’S NAME:  _________________________________________________________________________________

AGE & GRADE LEVEL as of September 2011: ________________________ SCHOOL/PROGRAM: ____________________
Parents’ Names:_____________________________________________________________________________________
Address: ___________________________________________________________________________________________

City/State/Zip:  _____________________________________________________________________________________
Phone Numbers:  ____________________________________________________________________________________
E-Mail Address: _____________________________________________________________________________________
To which yahoo groups do you belong?  __________________________________________________________________

In the event (1) of an injury or illness, (2) your family physician is not available or is not located in the immediate vicinity, and (3) (in the case of a minor) we are unable to contact one or the other parent, does the supervising person have your permission to seek medical attention from the nearest licensed physician and/or hospital?  

       YES      NO

If your answer is no, please specify the procedure you wish the supervising person to follow: 
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Signature (of parent or legal guardian if student is a minor)

I am/my child is covered by medical insurance:              YES       NO
Allergies:  __________________________________________________________________________________________
Emergency contacts/numbers during class time:  __________________________________________________________
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Doctor’s Name/Phone:  _______________________________________________________________________________

The following FEES are due with this form:

  2nd Semester Registration Only = $20/student  
Regular Registration = $50/student + 1/2 month's class tuition  

(Maximum Registration Fee of $90/Family.  Registration Fee is NON-REFUNDABLE . . . except 
Registration Fees and Tuition are fully-refundable within 3 days of receipt or if course is cancelled by The World Language House.)

Enclose cash or check payable to:

 The World LANGUAGE HOUSE
605 Muriel St., Richland, WA  99352

languagehouse@frontier.com                      (509) 627-7111 or 378-9751


 

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RE:  The World LANGUAGE HOUSE, ITS TEACHERS, & ITS STAFF

For:  _________________________________________________________

            Child(ren)’s Name(s)

FIELD TRIPS AND NEIGHBORHOOD PARK

We use the park across the street as our school yard.  We may take a walk, play on the equipment, or similar.  This provides us with the unique opportunity to discuss new concepts as well as to enjoy a change of scenery and a breath of fresh air.

Please sign here stating that you understand this part of our program and are in agreement with it.     __________________________________________

                                             Parent Signature

Special field trips outside of the immediate neighborhood may be planned at some time.  In this case, you would be asked to fill out a Field Trip release form giving permission for your child to join the excursion.  We may or may not need chaperones and/or drivers at that time; we would keep you advised.

RELEASE OF LIABILITY

We will extend every effort to watch out for you and/or your children with the same amount of care and concern as we would ourselves and/or our own.  In the case of an unexpected accident, however, which results in injury to you and/or your child, you agree to hold harmless Patricia Skirko/The World  Language House and its teachers from any damages and/or medical expenses incurred.

I agree:  _____________________________

                        Parent Signature

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Printed Name

Dated this _______ day of ______________, 2012