Bangor Chinese School
Registration Form for Children

Parent/payer information (Please give us both parents/guardians name if applicable)
Name: __________________________________________________________________
Name: __________________________________________________________________
Address: ________________________________________________________________
City:__________________________________State:_______________Zip:___________
Home Phone: ___________Work Phone:__________ Email:_______________________
Should we be unable to contact you in the event of an emergency, please list the name and phone number of a responsible adult we may contact. 
Name:___________________________________Day Phone:______________________

Participant Name	Sex	D.O.B.	Age	Grade	School	Fee	

							
Balance Due		

Please list any adults or relatives that are authorized to pick up your child. Be aware that a child will not be released to those who are not listed here or not listed as parent/guardian unless prior contact is made. 
Name:___________________________________Relationship_____________________

Signature:______________________________________Date:_____________________

NO REFUNDS WILL BE GIVEN AFTER A PROGRAM BEGINS