Please print the registration form (one form per child), fill it out, and mail it with your check(s) payable to Alliance Française de Buffalo before June 1st, 2010: Alliance Française de Buffalo Kathryn Missert 9 Redwood Drive Cheektowaga, NY 14225 For more information, contact Kathryn Missert by e-mail at kmissert@yahoo.com or phone at 716 833-4777 Child’s name: ____________________________________________________________________________ (first, last) Address: ________________________________________________________________________________ (street, city, zip) Phone number: ___________________________ E-mail: ________________________________________ Age: ____________________________________ Grade: ________________________________________ Has your child ever been exposed to the French language? Please explain. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Parent or guardian’s name: ____________________________________________________________________________ (first, last) Parent or guardian’s address (if different from above): ________________________________________________________________________________ (street, city, zip) Home phone: ________________________________ Work/cell phone: _____________________________ E-mail: _________________________________________ Emergency contact: ________________________________________________________________________ Emergency phone: _________________________________________________________________________ One-week session -choose session(s): Session I (July 5)___ $175 per child Session II (July 12)___ $175 per child Session III (July 19)___ $175 per child Session IV (July 26)___ $175 per child By day -circle date(s): Session I (July 5 - 6 - 7 - 8 - 9) Total_____ $35 per child/per day Session II (July 12 - 13 - 14 - 15 - 16) Total_____ $35 per child/per day Session III (July 19 - 20 - 21 - 22 - 23) Total_____ $35 per child/per day Session IV (July 26 - 27 - 28 - 29 - 30) Total_____ $35 per child/per day Early drop-off (8am) and late pick-up (4pm) -circle date(s) : Session I (July 5 - 6 - 7 - 8 - 9) Total_____ $7 per child/per hour Session II (July 12 - 13 - 14 - 15 - 16) Total_____ $7 per child/per hour Session III (July 19 - 20 - 21 - 22 - 23) Total_____ $7 per child/per hour Session IV (July 26 - 27 - 28 - 29 - 30) Total_____ $7 per child/per hour Tuition due per child (check one): _____ I am enclosing a deposit of $50 (full tuition due on the first day of class) _____ I am enclosing full payment I am not a member and our family will join the Alliance Française de Buffalo (check one): ___ Family ($50) ___supporting ($85) (on a separate check) I would like to receive a copy of the Alliance Française de Buffalo directory? (distributed to included members only): Yes ___ No ___ Merci! _____________________________________________________ ___________________________ Signature of Parent or Guardian and Date If you decided to become a member of the Alliance Française de Buffalo, it would help us understand you better if you would answer the questions below As a member, we would like to participate in the following activities
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