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ACES 2024 Spring Break Camp Enrollment Form
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Step
1
of 2
Student Information
Student Name
*
First
Middle
Last
Sex
*
Student Current School
*
Grade
*
Please Select One
PK
K
1st
2nd
3rd
4th
5th
Home Mailing Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Student's Mandarin Chinese Proficiency
Speaking
*
None
Some
Good
Listening
*
None
Some
Good
Reading
*
None
Some
Good
Writing
None
Some
Good
How many years has your child learned Chinese?
Which textbook has your child used before?
Ma Liping
Ji Nan
Other
How many books has your child learned?
Special needs
Allergies
Previous serious illness
Emotional or behavioral issues
Medication prescribed for long-term use
Any other information of which the ACES staff should be aware, please talk to us in person.
Parents Contact Information
Mother's Name:
*
Mother's Email
*
Mother's Phone
*
Father's Name
Father's Email
Father's Phone
Emergency Contacts and/or Authorized Pick-ups
Name
*
Work/Cell Phone
*
Authorized to Pick-Up?
Yes
No
Name
Work/Cell Phone
Dropdown
Yes
No
Name of Student Physician
*
Physician Phone
*
Parents Statement of Agreement
*
I understand that I am not to leave my child at the ACES site unless there is a ACES staff member present.
I understand that my child will not be allowed to leave the program with an unauthorized person. Only adults (over 18 years old ) can be authorized to pick up the child.
I understand that I will be charged a late fee if I fail to pick up my child before 6:00pm. The late fee will be $5 per 15 minutes.
Authorization: In case of an emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give permission to the physician selected by the adult leader in charge to secure proper medical services. I hereby release Austin Chinese Education Services and its staff and aides from all action that may arise from such medical services.
I understand and acknowledge that the ACES does not offer any medical insurance to protect against injuries, makes no claim to do so, and has no responsibility for any medical expenses incurred. I understand that each participant must assume the risk and any related financial responsibility that could result from participation in any of these activities. I agree to assume such risks and such financial responsibility. I further understand that neither the ACES nor its workers can be held responsible in the event of accident.
I acknowledge that ACES parents handbook is available at: Parents Handbook and it is my responsibility to read and understand the policies, provisions and procedures contained in the parents handbook.
I authorize for my child(ren) to participate in photos or videos for ACES Classes and/or events and may watch Chinese Children Cartoon series..
I understand that my child may be removed from ACES program for any of the following reasons:
Failure to pay program fees by designated deadlines
Inappropriate behavior of a child/parent that endangers anyone involved with the ACES
Inappropriate behavior of students that disrupt the class, so that the class cannot function properly
Next
Which Session(s) will your child attend?
Full Day Spring Break (3/11-15) Waiting
Half Day Spring Break (3/11-15）Waiting
Join by Day (3/11) Waiting
Join by Day (3/12) Waiting
Join by Day (3/13) Waiting
Join by Day (3/14) Waiting
Join by Day (3/15) Waiting
Total
$ 0.00
Electronic Signature
*
Clear Signature
By signing, I hereby acknowledge that I have read and understand this Parent Statement of Agreement, and agree to all the terms and conditions set forth above.
Signed Date
*
