Summer Camp - The French American Academy

Summer Camp
Application Form - Demande d’inscription
2013-2014
STUDENT INFORMATION
Student’s Last Name
Nom de l’élève
__________________________________________________________________
Student’s First Name
Prénom de l’élève
__________________________________________________________________
Student’s address
Adresse de l’élève
__________________________________________________________________
(Number, Street /Numéro et Rue)
__________________________________________________________________
(Town / Ville)
(State / Etat)
(Zip code / Code postal)
Home phone
Tél domicile
____________________________
Gender
Genre ___________________________
Date of Birth
Date de naissance
____________________________
Place of Birth
Lieu de Naissance
Countries of citizenship
Nationalité(s)
____________________________
School currently attending
Ecole fréquentée actuellement
Language(s) spoken at home
Langue(s) parlées à la maison
_________________
___________________________________
______________________________
Current Grade
Niveau de classe actuel ______
___________________________________________________________
Siblings / Frères et soeurs
First name - Prénom
Date of Birth - Date de naissance
Attending School - Ecole fréquentée
Grade - Classe
FABC does not discriminate on the basis of race, color, social origins, ethnicity or beliefs.
FABC accueille des élèves de tous horizons, indépendamment de leur origine sociale, ethnique et de leurs croyances et s’oppose à
toute forme de discrimination.
1092 Carnation Drive - New Milford, NJ 07646 - Tel: 201 338 8320 - Fax: 201 338 8321
Email: [email protected] - www.thefrenchabc.com
PARENTS / GUARDIAN INFORMATION
Mother’s Name
Nom de la mère ________________________________
Father’s Name
Nom du père ________________________________
Address
Adresse ______________________________________
Address
Adresse ______________________________________
(if different from student’s – si différent de celui de l’enfant)
(if different from student’s – si différent de celui de l’enfant)
Cell Phone #
Tél. portable __________________________________
Cell Phone #
Tél. portable __________________________________
Work Phone #
Tél. travail ____________________________________
Work Phone #
Tél. travail ____________________________________
Email
Courriel _____________________________________
Email
Courriel _____________________________________
MEDICAL RELEASE
I hereby release, discharge and/or otherwise indemnify The French Academy of Bergen County, Inc, its affiliated
organizations and sponsors, their employees and associated personnel, including the owners of the facilities utilized for
the program, against any claim by or on behalf of the student's participation in the school. My child has received a
recent physical examination by a physician and I have disclosed any and all known medical conditions to the French
Academy of Bergen County, Inc.
Therefore, I grant The French Academy of Bergen County, Inc. permission to act as my surrogate for my child in the area
of obtaining medical treatment by a doctor of medicine or dentistry. In the event that I cannot be reached, I give
permission to the authorities of the French Academy of Bergen County, Inc to seek emergency treatment at the nearest
hospital. I also assume financial responsibility for any medical treatment for my child.
Allergies and known medical conditions - Allergies ou autres conditions médicales :
Emergency contact (other than parent) :
Primary doctor :
Name : ____________________________
Phone # 1: _________________________
Phone #2 : _________________________
Name : ____________________________
Phone : ____________________________
Insurance information : Name : ____________________________
Phone : ____________________________
Signature : _____________________
Date : _________________
1092 Carnation Drive - New Milford, NJ 07646 - Tel: 201 338 8320 - Fax: 201 338 8321
Email: [email protected] - www.thefrenchabc.com
REGISTRATION
Full day: from 9am to 3pm
$435 per child and per week
$415 per child for any additional week, at the time of initial registration
Half day: from 9am to 1pm
$335 per child and per week
$315 per child for any additional week, at the time of initial registration
Check the week(s) you wish your child to attend :
□ full day
□ full day
□ full day
□ full day
□ full day
□ full day
□ full day
□ half day
□ half day
□ half day
□ half day
□ half day
□ half day
□ half day
July 8th – 12th
July 15th – 19th
July 22nd – 26th
July 29th – August 2nd
August 5th – August 9th
August 12th – 16th
August 19th – 23rd
I am investigating like a detective
I am playing in a circus
I am traveling with “Le Petit Prince”
I am taking a stroll in Paris
I am experimenting with Pasteur
I am an artist in a French-speaking world
I am exploring with Robinson Crusoe
Before and After Care – Check your choice :
□
□
□
□
I register my child in the aftercare, open from 3 to 6pm, with a flat fee of $60 per week payable in advance.
I register my child in the beforecare, open from 8 to 9am, with a flat fee of $20 per week payable in advance.
I understand that after 6pm, the cost is $5 per minute.
I will use before or after care only on an occasional basis. The cost is $10 per hour, payable in cash
on the same day. Any hour started is due in full.
Early bird: register and send your payment before April 1st, you will receive a 10% discount on the first week.
Field Trip: There is an additional charge of $30 per field trip if your week and age group offer a field trip.
To book your spot, please return this application form with a deposit of $400. An invoice will be sent to
you shortly after receiving your registration. Applications will not be processed without proper payments.
To receive the early bird discount, all payments should be made by April 1st.
For a registration after April 1st, all remaining payments, after the deposit, should be made by June 1st.
After June 1st, full payment is due at the time of enrollment. Any week started is due and non refundable.
There is a cancellation fee of $120.
1092 Carnation Drive - New Milford, NJ 07646 - Tel: 201 338 8320 - Fax: 201 338 8321
Email: [email protected] - www.thefrenchabc.com