Adult Student Application Form

STUDENT INFORMATION

Name *

Last Name, First Name, Middle Initial

Mailing Address *

Street, Town/City, State, Zip Code

Telephone Number *

Email *

What do you hope to gain from this course at The Filipino School of New York & New Jersey? *

EMERGENCY INFORMATION

In case of an emergency, please contact the following person:

Name *

Last Name, First Name, Relationship

Telephone Number *

Email *

COURSE REGISTRATION INFORMATION

Course/Program Name *

Year *

Semester *

Spring

Summer

Fall

Winter

Required

UNDERSTANDING OF POLICIES *

Yes

No

Liability Waiver: I will not hold FilSchoolNYNJ, its board of directors, employees, or volunteers responsible for any accidents, injury, or harm incurred during participation in FilSchoolNYNJ programs and activities. If either the emergency contact or doctor cannot be reached in case of emergency, consent is hereby given that I receive medical treatment.

Health Clearance: I am in good health and can participate in all FilSchoolNYNJ activities.

Attendance: I understand that daily attendance and promptness are required.

Consent to Photograph and/or Record: I understand that the images, film, videotape, audio recording, music, and/or artwork in which I will be participating is being produced by FilSchoolNYNJ. I hereby acknowledge that my participation may be edited and used in whole or in part as desired, and may be reproduced, duplicated, distributed and used for general education, marketing, and public information purposes. I consent to the use of my likeness and voice for information purposes in connection with the images, film, videotape, or music recording.

Confidentiality Policy: The information provided on this form is confidential. It is protected by The Family Educational Rights and Privacy Act (1974) and prohibits unauthorized access to student records and unauthorized release of any student record information identifiable by either student name or other personal identifiers.

Yes

No

Liability Waiver: I will not hold FilSchoolNYNJ, its board of directors, employees, or volunteers responsible for any accidents, injury, or harm incurred during participation in FilSchoolNYNJ programs and activities. If either the emergency contact or doctor cannot be reached in case of emergency, consent is hereby given that I receive medical treatment.

Health Clearance: I am in good health and can participate in all FilSchoolNYNJ activities.

Attendance: I understand that daily attendance and promptness are required.

Consent to Photograph and/or Record: I understand that the images, film, videotape, audio recording, music, and/or artwork in which I will be participating is being produced by FilSchoolNYNJ. I hereby acknowledge that my participation may be edited and used in whole or in part as desired, and may be reproduced, duplicated, distributed and used for general education, marketing, and public information purposes. I consent to the use of my likeness and voice for information purposes in connection with the images, film, videotape, or music recording.

Confidentiality Policy: The information provided on this form is confidential. It is protected by The Family Educational Rights and Privacy Act (1974) and prohibits unauthorized access to student records and unauthorized release of any student record information identifiable by either student name or other personal identifiers.

ACKNOWLEDGMENT & SIGNATURE

I hereby certify that the above information is true and correct to the best of my knowledge. I acknowledge and understand that the information provided here will be relied upon for purposes of determining my eligibility for this program. I acknowledge that a material misstatement fraudulently or negligently made in this or in any other statement made by me may constitute a federal violation and may result in the denial of participation in this program.

Name *

First Name, Last Name

Date *

Month, Day, Year

MM

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DD

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YYYY