Registration form JC - The French American Academy

PROGRAMME EXTRA-SCOLAIRE 2012-2013
2012-2013 AFTERSCHOOL PROGRAM
Prénom et Nom de l’élève : _________________________________________________________________
Student’s first and last name:
Date de naissance : ______(mois) _______(jour) _________ (année)
Date of birth:
(month)
(day)
(year)
Sexe :
Gender
M
F
Adresse : _________________________________________________________________________________
Address:
Ville : ___________________________________ Etat : __________ Code postal : _______________________
City:
State:
Zip code:
Tél domicile : ______________________ Adresse e-mail ____________________________________________
Home phone #:
E-mail address:
Langues parlées à la maison : 1.__________________ 2.____________________ 3. ______________________
Language(s) spoken at home:
Etablissement fréquenté et classe de votre enfant en Sept. 2012 : ______________________________________
Child’s current grade level and school:
Information sur les parents ou tuteur
Parent/ Guardian Information
Nom de la mère : _________________________
Mother’s name:
Nationalité : ___________________________________
Nationality:
Tél cellulaire : ____________________________
Cell phone #:
Tél bureau : ___________________________________
Work phone:
Profession:______________________________
Occupation:
Adresse e-mail :________________________________
E-mail address:
Nom du père : ____________________________
Father’s name:
Nationalité : ___________________________________
Nationality:
Tél cellulaire : ____________________________
Cell phone #:
Tél bureau : ___________________________________
Work phone:
Profession :_______________________________
Occupation:
Adresse e-mail:________________________________
E-mail address:
Comment avez-vous connu The FAJC ?
How did you learn about the FAJC?
Portes-ouvertes
Amis
Site internet
Open House
Friends
Website
Publicité
Advertising
Autres : _____________
Others
Quelles sont vos attentes ?
What are your expectations for this program?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
French Academy of Jersey City, 209 Third Street, Jersey City, NJ 07302
•Date d’entrée dans le programme / Start date : ______________ Groupe / Group : ______________
•Jour(s) souhaité(s) :
lundi
mardi
Selected day(s) for class:
Monday
Tuesday
GROUPES 2,5 - 10ans
2.5-10 years old
mercredi
Wednesday
jeudi
Thursday
samedi
Saturday
Ne pas remplir
Please leave blank
Paiement annuel
Paiement en 3 fois (Three installments)
(Full payment)
(At registration)
A l’inscription (At registration)
10 Décembre (December 10, 2012)
18 Mars (March 18, 2013)
$1023
$429+$429+$215
$1292
$545+$545+$273
$2196
$924+$924+$462
$625
$264+$264+$132
$1313
$552+$552+$276
A l’inscription
Classe de 1h30
1.5-hour class
Classe de 2h
2-hour class
Double session 1,5h + 2h
Double session (1.5 hours + 2 hours)
Classe Eveil 18-30 mois, 1h
Baby & Me class, 18-30 months-old, 1 hr.
Classe Adulte 1h30
Adult class, 1.5 hours
vendredi
Friday
Paiement à l’avance, avec un minimum de 5 leçons
Cours privés / semi-privés
Full payment due at registration; minimum of 5 lessons
Session semi-privée pendant 1 heure, de 2 à 4 étudiants
Semi-private lesson, 1 hour, up to three students
Session privée, 1 heure
Private lesson at home, 1 hour
Paiement choisi / Selected payment option:
Montant / Amount
10% réduction pour frères et soeurs / 10% discount for siblings
Frais de 1ère inscription* / One-time registration fee* ($40):
Total :
$45
$75
annuel (full) / en 3 fois (3 installments)
________________
________________
________________
________________
Paiement par chèque à l’ordre de FAJC / Please make checks payable to: FAJC
* Les frais de 1ère inscription, de $40.00, sont non remboursables et dus pour les nouveaux élèves uniquement.
The one-time registration fee of $40.00 is applicable to all new students. Please note that this fee is non-refundable.
*Il y a une classe de rattrapage pour chaque session de 10 classes, dans la mesure du possible, sans obligation de la part de l’école.
The school will make every attempt to offer one (1) make-up class for each trimester with 10 class sessions.
Signature : ________________________ Date : ________________
La French Academy of Jersey City accueille des élèves de tous horizons, indépendamment de leur origine sociale,
ethnique et de leurs croyances et s’oppose à toute forme de discrimination.
The French Academy of Jersey City does not discriminate on the basis of sex, race, color, religion, creed, age, national
origin, ancestry, pregnancy, marital status or parental status, sexual orientation, or disability.
French Academy of Jersey City, 209 Third Street, Jersey City, NJ 07302
MEDICAL RELEASE
I hereby release, discharge and/or otherwise indemnify The French Academy of Jersey City, Inc., its affiliated
organizations and sponsors, their employees and associated personnel, including the owners of the facilities utilized for
the program, against any claim by or on behalf of the student's participation in the school. My child has received a recent
physical examination by a physician, and I have disclosed any and all known medical conditions to the French Academy
of Jersey City, Inc.
Therefore, I grant The French Academy of Jersey City, Inc. permission to act as my surrogate for my child in the area of
obtaining medical treatment by a doctor of medicine or dentistry. In the event that I cannot be reached, I give permission
to the authorities of the French Academy of Jersey City, Inc. to seek emergency treatment at the nearest hospital. I also
assume financial responsibility for any medical treatment for my child.
Student’s name: ____________________________
Address: ______________________________________________________________
Date of birth: _____________________
Emergency contact name (relationship to student): ____________________________
Phone # 1: ____________________
Phone # 2: ____________________
Primary doctor: ____________________________
Doctor’s phone #: ______________________
Allergies ou autres conditions médicales
Allergies and all known medical conditions:
Insurance information:
Name: ________________________________
Phone: _______________________
Signature: _____________________ Date: _________________
Authorization to Publish
I understand that my child’s picture may appear in the newspaper, television, FABC’s website, brochures, or newsletters.
□ I authorize my child’s picture and work to be published. No name will appear with the picture.
□ I do not authorize my child’s picture and work to be published.
Signature : ______________________________ Date : _________________
French Academy of Jersey City, 209 Third Street, Jersey City, NJ 07302