Need to Register Multiple Students? *

Student's Name *

Parent Name, if registering for a child: *

Age of Student *

Address *

Email *

Primary Phone Number *

Secondary Phone Number *

Course Terms for 2012 *

Headstart Mandarin (4-6 Yrs Old) *

Intro Mandarin Youth (7-17 Yrs Old) *

Intro Mandarin Adult (18 yrs old & Above) *

Headstart Mandarin - Level 2 (4-6 yrs old) *

Mandarin for Youth – Level 2 (7-17 yrs old) *

Mandarin for Adults – Level 2 (18 & above) *

Adult Business Class *

Home Schooled Students *

Grade 1 *

Grade 2 *

Grade 3 *

I authorize the following to pick up my child/children, with full name and contact number: *

Emergency Contact, with full name and contact number: *

Comment *

How did you hear about us? *

I hereby consent to the participation of interviews, and the taking of photographs, movies, or video of the student named above. I also grant to Greenery Arts LLC the right to edit, use, and reuse the said products for its own and promotional purposes including use in print, on the internet, and all other forms of media. In addition, I release Greenery arts and its employees from all claims, demands, and liabilities whatsoever in connection with the above. *

In case of emergency, when I cannot be reached, or if I myself require assistance, I authorize the staff of Greenery Arts to obtain whatever medical treatment is deemed necessary for the welfare of myself (if I am a student), my child, or other dependent students. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether or not my medical insurance would cover such charges and fees. Furthermore, I hereby give my consent to my, my child’s, or my dependent's participation in the activities of Greenery Arts and hereby absolve, release and hold harmless Greenery Arts and all of its staff from any and all liability for any injuries or damages that any of the aforementioned may suffer personally, or to their personal property, in connection with the activities in which we may participate. I also will be liable for all the property damages caused by any of the aforementioned. I understand that Greenery Arts cannot assume responsibility for children left at Greenery Arts facilities before and after program hours. Greenery Arts reserves the right to change the schedule, level and/or terminate a student, if deemed necessary. I also understand that all fees are non-refundable, once classes have started. *