SAT/PSAT Math and Computer program registration

Name


A red asterisk (*) indicates required questions.


  1. Child’s Name in English(Last, First): *


  1. Child's Chinese Name: *


  1. Gender*
    male
    female


  1. age (By August 1, 2012)*
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
    16
    more than 16


  1. Current grade at school (By June, 2012) *
    Kintergarten
    1
    2
    3
    4
    5
    6
    7
    8
    above 8th


  1. your address*


  1. Mother/guardian name*


  1. Mother/guardian phone number*


  1. father/guardian name*


  1. Father/guardian phone number*


  1. parent email address*


  1. SAT/PSAT Math Lab: August 13-24, 3pm-4pm
    Program fee: $60/week; $100/two weeks*
    my child will attend for first week. Program fee: $60
    my child will attend for second week. Program fee: $60
    my child will attend for two weeks. Program fee: $100
    No, my child will not attend.


  1. Computer Game Programming and Design Class (1pm - 3pm)*
    my child will attend for first week. Program fee: $110
    my child will attend for second week. Program fee:$110
    my child will attend for two weeks. Program fee: $200
    No, my child will not attend.


  1. Extended service: 4-6pm
    Additional Fee: $20/week; $40/two weeks*
    my child will need the extended service for the first week. Fee: $20
    my child will need the extended service for the second week. Fee: $20
    my child will need the extended service for the both weeks. Fee: $40
    No, my child don't need this service.


  1. Emergency Contact Information
    In case of emergency, please list two responsible adults who could be notified by the school.
    Name and phone number*


  1. Doctor’s name and contact Phone *


  1. Allergies or other medical conditions the school should know: *


  1. Photo Release Agreement
    I grant to Southern Connecticut Chinese School (SCCS) the right to take photographs of my child in this Chinese summer camp. I authorize SCCS, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
    I agree that SCCS may use such photographs of my child without his/her name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.*
    Yes
    No


  1. Parent/Guardian agreement
    I, the undersigned parent or legal guardian of the above child(ren) do give my permission and approval for his/her participation in SCCS Chinese School program(s) and therefore, assume all risks and hazards incidental to such participation. On behalf of my child(ren) and family, I freely and voluntarily agree to release, indemnify and hold harmless, the SCCS Chinese School, its directors, officers, administrators, teachers, and volunteers from any liabilities arising from any incident to my child(ren)'s involvement and participation in the school's program(s). I also have read and understand SCCS Chinese School’s Admissions Policy, Refund Policy, and Policies and Procedures on the SCCS Chinese School web site (http://www.ynhchineseschool.org). I understand that if my child displays inappropriate behavior, he/she (or I) may be dismissed from the program and no refunds will be given. *
    Yes
    No


  1. Please submit a current copy of Physical or Health Form (as of 8/1/2012; available from your physician), it is required on or before the program start date (8/13/2012). *
    Yes, I will
    No


  1. Payment: Please mail the payment check to:

    Summer Section 2012
    Southern Connecticut Chinese School
    P.O. Box 2097
    74 Washington Avenue
    North Haven, CT 06520
    *
    Yes, I will
    No, I will pay it at summer camp site.