Plainview Chinese Learning Center 2023 Summer Program Registration
Program is from 7/5 - 8/11 (M-F) at 9am-12 pm
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Student's Name
Date of Birth *
YYYY
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MM
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DD
Address *
Home Phone/ Cell Phone Number *
Parents Name
Authorized Pick Up Individuals (name & phone#)
Parent's Email *
Student's Grade in September *
Student's T-shirt Size *
Choose preferred session *
Vaizdas be antraštės
Will you be interested to enroll in the after school in Sept 2023?  *
Will you enroll in the Sat Chinese school program in Sept 2023? or Refer a friend*  $100 Credit for Summer 2023 *
Choose Total Payment *
Privalomas
Choose Form of Payment *
Please state any allergies or health conditions *

As the parent or legal guardian of the above student, I hereby give permission for my child to participate in the Plainview Chinese Learning Center (PCLC) programs. In case of accident or injury, and if an emergency contact person cannot be reached, I grant PCLC permission to obtain medical attention for my child if necessary, for which I will be financially responsible. I hereby release PCLC and the staffs of PCLC from any and all responsibility. By signing below, I hereby comply with PLCC’s policies and regulations.

Notes: Tuition and fees are nonrefundable. The programs and fees are subject to change/cancellation.  Field trip fees will be extra.

Parent's Electronic Signature *
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