The Español Experience

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

SPRING 2024: 12 Weeks

Sibling Discount: 15%

Qty

Description

Amount

Total

First Child

$240.00

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Sibling(s)

$200.00

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Total: $0.00

Student Information

Registration is complete when payment is made for each child.

Student #1 First Name: *

Last Name: *

Class Selection: *

Gender: *

Age: *

Date of Birth: *

(xx/xx/xxxx)

School: *

Borough/County: *

Grade *

Best describes student: *

If your child has any health concerns or restricted activities please explain below or enter NONE.

If the student has an IEP or requires a paraprofessional during the school day, please contact us prior to registration to discuss your child’s specific needs. If none, please enter NONE.

Health Concerns/
Restrictions: *

Restricted Activities: IEP or Special Needs
MUST BE DISCUSSED PRIOR TO REGISTRATION *

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1
First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Cell Number: *

Secondary Number:

Email: *

Check here to receive tips and resources at the above email to help your child grow their Spanish skills.

EMERGENCY CONTACTS (OTHER THAN ABOVE)

Emergency #1 First Name:

Emergency #1 Last Name:

Address: *

City: *

State: *

Zip Code: *

Cell Number: *

Secondary Number: *

Email: *

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Cell Number:

Email:

Release Agreement

Release Agreement: *

I understand this class meets online, and I will make available a safe place, free of distractions, from which my child will log on. I have indicated on this form any restrictions or special needs my child has, and I understand that those must be discussed with The Español Experience in advance of registration in order to ensure it is properly equipped to serve my child’s needs. I also understand that my child’s participation in program activities may be photographed or videotaped for use by The Español Experience for promotional and/or educational training purposes. Finally, I understand that students exhibiting disruptive behavior or disrespectful words/actions directed at staff or fellow students will be asked to leave the program. By checking this box I indicate that I have read and agreed to these conditions.

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *