Discovering Languages - Foreign Language Immersion Program

Online Registration Form

To register online, please fill out the form below.
--When you click "Submit," you will be taken to another page where you can make your payment on a secure site or you can send a check via regular mail.
--Also, when you click "Submit" a copy of your registration will be sent to us. We will e-mail you a confirmation that we received your registration. If you do not receive a confirmation e-mail within 48 hrs. please contact us.
--If you prefer NOT to register online, please e-mail us at info@discoveringlanguages.com for a paper copy.

Child's name:
Gender:
Date of birth:
Child's age:
Address:
Zip code:
City:
E-mail:
Child's school:
Mother's name:
Mother's daytime and/or work/cell number:
Father's name:
Father's daytime and/or work/cell number:
Languages spoken at home:
Previous language instruction?:
If yes, how many years?:
Who has permission to pick up your child?:
Emergency Contact:
Emergency Contact Phone Number:
Medical: Physician's name:
Medical: Physician's phone number:
Medical Insurance Policy & Number:
Dental: Dentist's name:
Dental: Dentist's phone number:
Dental Insurance Policy & Number:
Medical Conditions and/or Limitations:
Medical care::	My child is under a phyisican's care or is taking medications on a continuing basis?
If yes, list medications:
Allergies:	My child has allergies.
If yes, list child's allergies:
Medical Release:	By checking this box, I hereby authorize the staff of Discovering Languages to seek medical treatment for my child, at the nearest facility, in the event of an emergency. In the event that non-emergency medical care is required, I authorize the staff to seek medical treatment through my child's physician. I understand that I am responsible for necessary medical expenses incurred by my child.
	By checking this box, as with any activity, I understand there may be risk of injury or harm. I agree to hold Discovering Languages, Michael and Natalia Benjamin, their family, and any volunteers or staff, harmless from liability for injuries or harm that may occur from participating in this program. I also agree to hold Discovering Languages, Michael and Natalia Benjamin, their family, and any volunteers or staff, harmless from, and indemnify them for, any damage or loss arising as a result of my child(ren)’s participation in Discovering Languages classes, summer camps, or activities.
	By checking this box, I understand that my child’s likeness may be used in promotional photos, website material, or various other marketing. These images will be used for Discovering Languages purposes only, and will not be given or sold to outside companies or individuals.
2009-2010 Class Preference






How did you hear about Discovering Languages?:
Comments:
	After you click "Submit," you will be taken to another page to make a secure payment. You can disregard that page and send your payment via mail if you prefer. You will receive an e-mail confirmation of your registration. Please contact us if you do not receive one.