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Registration
| Your Child's Name: |
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| Parents/Guardians Name: |
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| Street Address: |
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| City: |
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| State: |
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| Zip: |
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| Email: |
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| Home Phone: |
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| Cell Phone: |
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| Emergency Contact: |
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| Emergency Phone: |
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| Food Allergies: |
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| Home School: |
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| Current Grade: |
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| Desired Language: |
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| Second Choice (optional): |
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| Childs Age: |
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| Please provide information if your child has a disability.* You may also call Belanno at 920-202-3431. |
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| Billing Information |
| Name on Credit Card: |
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| Credit Card Type: |
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| Credit Card Number: |
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| Expiration Date: |
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| Amount to be Charged: |
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| Billing Zip Code: |
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SSL Certificates |
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| I hearby give permission for my child to particpate in courses sponsored by Belanno. I waive and release all rights for claims that I have against Belanno for damages or injuries to my child that may occur while participating in the Belanno Summer program. I understand that reasonable safety precautions will be used during the classes. I am responsible for prompt pickup and drop-off of my child. Belanno instructors are trained to work with groups of children. I understand that should my child have difficulty cooperating, the teacher will telephone me to ask me to talk with my child and clarify classroom expectations. If the problem continues and jeopardizes other children's learning. I understand that I may be asked to withdraw my child from the program with no refund. Belanno reserves the right to cancel any class for any reason. A full refund will be granted. By clicking the submit box above, you acknowledge and agree to the statement herein. |
| * Belanno does not discriminate against students on the basis of sex, race, religion, national origin, ancestory, creed, pregnancy, marital or parental status, sexual orientation, or physical, mental, emotional, or learning disability or handicap in its programs or activities. Federal law prohibits discrimination on national origin, sex, religion, or handicap. |
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