Blue Giraffe of Washington DC 19-20 Registration

Blue Giraffe of Washington DC 2019-20 School Year Registration

Russian speakers programs
Child Information
Saturday Program 2-3-4-5 years old Sunday program 5-6-7-8-9-10-11 years old
Child's Name *

First Name Last Name
Child's Birth Date *

Month Day Year
Last Grade Completed *
Medical or other information we may need to know about the child (including food allergies). Special needs: (physical; developmental; behavioral/emotional; sensory). This information helps our staff to do their best to accommodate all of our students particular needs. *
Parent/Legal Guardian Name *

First Name Last Name
Parent/Legal Guardian Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Emergency Contact 1 (other than parent/guardian listed above) *

First Name Last Name
Emergency Contact 1 Phone Number *

Area Code Phone Number
Emergency Contact 2 (other than parent/guardian listed above) *

First Name Last Name
Emergency Contact 2 Phone Number *

Area Code Phone Number
Media Release
By clicking the box below, I hereby Give Permission for photographs and/or video in which my child's art works appear in to be used by Blue Giraffe in printed and/or electronic media, including the Blue Giraffe's website and FB page. *

I Agree I Disagree
By clicking the box below, I hereby Give Permission for photographs and/or video in which my child appears in to be used by Blue Giraffe in printed and/or electronic media, including the Blue Giraffe website and FB page. *

I Agree I Disagree
Late Pick-Up Policy
LATE PICK-UP POLICY FEE AND PROCEDURE: Up to 15 minutes: Automatic flat $15.00 late fee is charged. After 15 minutes: Automatic flat $25.00 late fee is charged *

I Agree
Understanding the Program
By clicking the box below, I hereby acknowledge that there are NO refunds or make-ups for missed classes, except Art classes. I understand that this is a program that exist as one whole program and can not be divided by individual days or classes. *

I Agree
Authorization for Medical Treatment
In the event that parents/guardians named on this form cannot be reached, I authorize officials of the Blue Giraffe Education Center to consent on my behalf, to provide emergency treatment for my child *

I Agree
Signature *

Clear

Registration Fee for New Students $ 55.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Should be Empty:

Blue Giraffe of Washington DC 2019-20 School Year Registration

Child Information

Media Release

Late Pick-Up Policy

Understanding the Program

Authorization for Medical Treatment