Child's Name:___________________________________________________

Age:____________ Grade:_____________________ DOB:________________

Location (Alb or BS), dates and time that you are registering for:________________________

Language registering for:___________________________________________________

Previous instruction in a foreign language? ____________________________________

How much and where?:____________________________________________________

Allergies:_______________________________________________________________

Please list names of individuals authorized to pick up your child:
                     
Name:_____________________Relationship:__________________________________

Name:_____________________Relationship:__________________________________

Photo release authorization:
Kim Andersen and/or local news organizations have my permission to photograph
my son/daughter during class time, to be used for promotional purposes of
the Capital Region Language Center.  

Signature:______________________________________________________________

Parent Contact Information

Name:__________________________________________________________________

Address: _______________________________________________________________

Phone Numbers:  Which is the best way to reach you at the last minute?___________

(H):______________________(C):___________________(W):____________________

Email:__________________________________________________________________

Method of payment:
_cash
_check 
_credit card (MasterCard/Visa/Discover) Please call 884-4652 with the following information:
CC number, expiration date, CV code, billing street address and zip code

Release
I have read the course description and the information about school policies.

Signature:_______________________________________________________________

Please print the registration form and send or bring it with payment to Capital Region Language Center.

If you have any questions email or call us at 518 884-HOLA (4652).