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课后班注册表
发布日期:2010-03-12   阅读次数:1488
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      伟博教育中心课后班注册表
                                                     WEI BO LEARNING AFTERSCHOOL REGISTRATION FORM
                                           136-20 38AVE 9A FLUSHING NY 11355      TEL: 718-353-5599  646-666-3778
中文和英文姓名Chinese Name & English Name    _________________________   性别Gender    ______
出生日期 Date of Birth  _____________  日间校名Day School Name  ______________  年级Grade  ____
是否接送 Pick Up & Send Home ______可以接我孩子之人Names that can pick up my child  _________
地址Address    ____________________________________________ 放学时间Dismissal Time  __________   
家长或监护人姓名Parent or Guardian ________________________电话Tel _________________________
就医授权:假如发生意外事故,唯恐伟博教育中心联络不到您,能否请提供两位可以代替您照顾或负责学生
就医的亲戚朋友的电话If your child gets into an accident and we are unable to reach you, please  
list two relatives or friends who will take responsibility in seeking medical attention.
紧急联系人姓名电话 NAME & TEL OF PERSON/S TO CONTACT IN CASE OF EMERGENCY (OTHER THAN PARENT) 
1._______________________________________   2.____________________________________
家庭医生Family Doctor_______________________            电话Tel    _______________________
是否有过敏Any Allergies __________________________________________________________  
我在此授予权力给伟博教育中心的工作人员,为我的孩子获得必要的紧急医疗治疗,并尽快通知我们家人
I do hereby give authority to the day care program staff to obtain necessary emergency medical 
treatment for my child, with the understanding that the family will be notified as soon as possible.
学生家长签名 Parent's Signature______________     日期Date__________与学生关系Relationship______
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以下部分由学校填写                                                                                                                   学号No.
学费 Tuition                              注册费Registration Fee                                   制服Uniform                                      
合计Total                                  (自From :日期Date                                   至To:日期Date                                   
合计实付Total Payment   $                                                       尚欠Due $                                                    
经办人签名Recipient of this registration & payment____________       日期Date_____________________
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