Student's Name 学生姓名 *

First Name

Last Name

Phone 联系电话 *

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Attending Weeks 暑期班时间 *

Select the weeks that you want to Attend 选择您孩子参加暑期班的时间

6/2 - 6/6

6/9 - 6/13

6/16 - 6/20

6/23 - 6/27

6/30 - 7/4

7/7 - 7/11

Course Selection 课程选择 *

Elementary Mandarin 中文初级班

Intermediate Mandarin 中文中级班

English - All levels 英文班

Contact #1: Name 监护人一的姓名 *

First Name

Last Name

Phone 电话 *

(###)

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Contact #2: Name 监护人二姓名 *

First Name

Last Name

Phone 电话

(###)

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Electronic Consent to Medical Emergency Terms/Conditions *

In case of medical emergency, I understand that every reasonable attempt will be made to contact me or the emergency contact named above. However, in the event that I or my named contacts cannot be reached, I give my permission to the adults in charge of the programs to secure and receive emergency medical or first aid treatment for my child, including transport via ambulance to a hospital if necessary. I consent to the sharing and release of any medical information listed above with the appropriate staff members of the program and/or medical personnel that may be necessary to ensure the safety and wellbeing of my child. I agree to pay for any charges for emergency medical treatment that are not covered by my personal health insurance.

I AGREE to the Terms Above

Release and Waiver *

I, the undersigned, hereby acknowledge that certain risks of injury are inherent to any program, including but not limited to participation in recreational activities, a child’s failure to follow instructions of supervisors, communicable illness, and independent acts of third parties not under the control of supervisors. I acknowledge that all risks cannot be prevented, and assume those beyond the control of the staff. These types of injuries may be minor or serious and may result from one’s actions, or the actions or inactions of others or a combination of both. I will take responsibility to see that I am prepared for all activities and am in good health each day of the session. I hereby assume all risks associated with participation in Charis Chinese Academy and agree to hold harmless to Charis Chinese Academy, Charis Alive, the Church of the Servant (the Church), its directors, officers, employees, volunteers, et al, from and against any and all claims, damages, demands, action or right of action, losses or liability of any kind or nature which may arise in connection with injuries suffered to me while enrolled/participating in their program. I have read and understand the above informed consent agreement in its entirety and hereby give my consent to participate knowing all of the foregoing.

I AGREE to the Terms Above

Consent to Photo/Video Release *

I understand that CCA may produce promotional material relating to its activities. As a participant at CCA, I may be included in videotapes or photographs taken during the camp. I grant to CCA the right to photograph and/or videotape me and to utilize such videotapes and photographs, my name, face likeness, voice and appearance as part of the camp.

I AGREE to the Terms Above

Transportation *

I certify and agree that I am to pick-up and drop-off my child only at the designated places and times.

I AGREE to the terms above

Consent to Rules and Expectations *

I understand that my child must abide by the rules and behaviors expected to ensure everyone’s safety and enjoyment of CCA. Failure to comply with these rules may result in the child’s removal from CCA. I will notify the CCA Supervisors immediately of any injuries the child sustains, any inappropriate behavior, or of any incidents of sexual misconduct, harassment or assault.

My child/children and I AGREE to the terms above