REGISTRATION FORM

CHINESE LANGUAGE PROGRAM

43 Fenimore Road Scarsdale, NY 10583

Student Information
Student's Name (English) *
Student's Name (English)
Student's Name (Chinese)
Student's Name (Chinese)
Date of Birth *
Date of Birth
New CLP students only
Second Student's Information
Second Student's Name (English)
Second Student's Name (English)
Second Student's Name (Chinese)
Second Student's Name (Chinese)
Date of Birth
Date of Birth
New CLP students only
Contact Information
Mother's Name *
Mother's Name
Home Phone *
Home Phone
Mobile *
Mobile
Work
Work
Father's Name *
Father's Name
Mobile *
Mobile
Work *
Work
Address *
Address
Caregiver's Information
Caregiver's Name
Caregiver's Name
Mobile
Mobile
Emergency Contact
Name *
Name
Phone *
Phone
Physician's Name *
Physician's Name
Phone *
Phone
Including physical challenges, transitional issues, etc. for each child
Please Indicate 1st, 2nd and 3rd class time preferences.
Parent and Me
Birth to 30 Months
3-4 Year Old
5-6 Year Old
7-9 Year Old
10-13 Year Old
Please indicate 1st, 2nd and 3rd class time preferences.
Parent and Me
Birth to 30 months
3-6 Year Old
5-8 Year Old
8-13 Year old
Tuition Information 15 session
If a class is not on the schedule please ask for availability.