Application for Extended Language School

1. Application for Extended Language School please return with $25 application fee First Name ___________________________ Last Name _________________________ (name of legal guardian if under age 18: __________________________________________________________________________________________________________________) birthdate ___________________________ SS#__________________________________ Home Address ______________________________ _____________________ ________street city/state zip code cell phone _______________ cell phone ____________ home phone ________________ email ___________________________ email __________________________ EMERGENCY CONTACT ____________________ _______________name phone number Physician’s name _______________________ Address/Tel. _______________________ I/We do hereby authorize emergency medical care if necessary:____________________________ ___________signature of parent/guardian date Signature: ______________________ Date: ______________________ I agree to obtain all rules and regulations regarding the Extended Language School and understand that the deposit and membership fees are non-refundable and non-transferrable. The Extended Language SchoolTel: (423) 303-8432 Brigitta HoeferleDirector and Founder For Admin only Reg. No: _______________________ Pre Registration Orientation:_______________________ Fees:Application $ 25.00 Starting Date: ________________ Language: __________________ Schedule: Friday 4 pm - 5 pm Saturday 9 am - 11 am The Extended Language School admits and enrolls individuals from all cultural, socio-economic, ethnic and religious backgrounds, without regards to disabilities.