Indonesian Language Class Registration Form for Children (Aged 7-14)

Bahasa Indonesia Course

Application  Form for Children Age 7-14

Beginner class sessions: Saturdays / March 4, 2017 - April 8, 2017 (6 class sessions)

Time: 11am - 1pm

 

    STUDENT INFORMATION

    Student's Full Name

    Gender

    Birth Date (yyyy-mm-dd)

    Place of Birth (city, country)

    Current School Grade & Name

    Medical/allergy Information

    Other useful note about the student, e.g. learning style, interests, etc. (optional)

    Will this student's placement in our class be part of the Family Package?

    If you choose 'Yes' on the above question, please insert names of your other family members that will participate in our classes. Max. 2 other family members to be included in the Family Package.

    (Please separately register the other family members mentioned above once you are done with this student's registration)

    PARENTS INFORMATION
    This information is needed in case of emergencies and for easy update on student's progress to parents. You can either insert both names and information of the parents or just one parent, as long as he/she is the current legal guardian of the student.

    Mother's Full Names

    Father's Full Names

    Parents Occupation (optional)

    Mother's Email Address

    Father's Email Address

    Mother's Cell Phone

    Father's Cell Phone

    Home Address

    Home Phone

    How did you hear about this course? I.e.: from friends, FB, ICONE's website, twitter, other links, etc.

    PAYMENT

    Individual tuition fee: $180/student for 6 class sessions (1 1/2 months)

    Also available, Family Package tuition fee:
    1.$325/2 family members for 6 meeting sessions (1 1/2 months).
    2.$475/3 family members for 6 meeting sessions (1 1/2 months).

    Payment method:

    If you choose payment by check, please mail check to:
    Yana Regan / Indonesian Community of New England, Inc.
    400 Washington St., Suite 408
    Braintree, MA 02189

    Payments for Family Package can be done by checks to the address stated above.
    Checks must be received by us within 1 week of application submission.

    For comments or questions, please email us at: contact@icone-inc.org

    Please click the 'Submit' button below to confirm your registration. Once you click the button below, please wait for few seconds until the page for payment appears.

    Thank you.

    [paypalsubmit email:contact@icone-inc.org sandbox]