2021-2022 After School - Enrollment 2021-2022學年課後班報名表
中文課時間: 星期一到星期四的下午三點到六點，星期五的三點到三點五十分
才藝課時間: 星期五的四點到六點

每月學費
日期五天$355
日期任選三天$335
*星期五才藝課程另外收取$20費用
書本費$20 (每位學生) 及註冊費$20 (每學年一次)

*送出報名表後, 您將會收到確認及付款訊息, 謝謝您!
**每一份報名表格限填一位學生


Chinese Program: 3 to 6 pm, Monday to Thursday & 3 to 3:50 pm on Friday
Enrichment Class: 4 to 6:00 pm on Friday

Monthly tuition fee
5 days per week $355
3 days per week $335
*Additional $20 for Enrichment Classes on Fridays.

Textbook/workbook $20 per kid and Document processing fee $20 per school year

*After submitting, you will be receiving confirmation and payment instruction. Thank you!
**Please complete one for each student.
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學生的英文姓名  Student's English Full Name *
學生的中文姓名  Student's Chinese Full Name
學生的出生日期  Student's DOB *
MM
/
DD
/
YYYY
學生目前就讀學校/年級  Student's Current School Name/Grade *
上課地點  School Location *
家長/監護人/父親姓名  Parent/Guardian/Father's Full Name *
家長/監護人/父親聯絡電話  Parent/Guardian/Father's Contact Phone No. *
家長/監護人/父親郵件信箱  Parent/Guardian/Father's Email Address *
家長/監護人/母親姓名  Parent/Guardian/Mother's Full Name *
家長/監護人/母親聯絡電話  Parent/Guardian/Mother's Contact Phone No.
家長/監護人/母親郵件信箱  Parent/Guardian/Mother's Email Address
郵寄地址  Mailing Address *
請仔細閱讀以下課程費用   Please read the following fee carefully.
費用(Tuition, Textbook & Document Processing Fee):    
中文課程
1.學費(Tuition per month):
 [   ] $355  M.T.W.Th.F. (星期一至星期五)        
 [   ] $335  any 3 days (任選三天)
 *Additional $20 required on Fridays for enrichment classes 星期五才藝班每月$20
 
2.書本費(Textbook Fee): $20 Per student / $20課本費
3.資料處理費(Document Processing Fee): $20 Per Family
報名的課程時間(任選三天請註明天數)   After School Schedule(If 3 days, Please Specify The Days) *
退費辦法   TUITION REFUND POLICY *
課後班學費一旦繳交以後無法退還，除非有特殊情況可以保留金額到後面的學期 (限當年度)。 There are no refunds issued for the after school program, but we can issue tuition credit for later sessions if necessary (credit is limited to the same school year).
Required
本人同意並授權聖瑪利諾中文學校拍攝、修飾、使用、公開展示本人與法定代理人的肖像、影片與聲音。聖瑪利諾中文學校可使用授權肖像來展示及宣傳服務項目。並得用於設計、製作、印刷、傳播、網站與新聞等各項廣告宣傳資料或以各種方式來呈現授權肖像之全部或部分且可公開發表，及著作權法賦予著作人所擁有之權益。聖瑪利諾中文學校可無須再通知或經由本人與法定代理人同意，但於公開發表時必須尊重個人形象，不得發表於非正當管道。  I hereby give the Chinese School Of San Marino permission to use photographs/ video/ sound of the adult and the minor(s) named below for publicity, promotion, news releases, videos, advertisements and web use of the Chinese School Of San Marino. This might also apply to written compositions or visual art pieces of minors if they are published. I hereby release and discharge the Chinese School Of San Marino from any and all claims arising out of the use of the photography/ video/ sound that I or the minor(s) listed may have in this regard. *
如果在緊急狀況下無法聯絡到家長或監護人，請通知下列人士，本人委託他們代為決定。   In the event I cannot be contacted, please notify the following Emergency Contact Person to whom I would be willing to have my child released.
請注意: 學校不會將學生授權給緊急聯絡名單外的任何人士，請列出最少二位姓名與他的證件相符。  Please note: We cannot release your child to any additional persons unless their name is listed below. Please list at least 2 names as they appear on Photo IDs.
第一位緊急聯絡人姓名及電話   #1 Emergency Contact /Phone No. *
第二位緊急聯絡人姓名及電話   #2 Emergency Contact /Phone No. *
第三位以後的聯絡人姓名及電話   Other Emergency Contacts /Phone No.
學生保險及號碼  Insurance Carrier/Policy No. *
家庭醫師及聯絡電話   Family Doctor/Phone No. *
過敏情形 (如果沒有請標註: 無)  Allergies (If No, Please List N/A) *
學生就讀於聖瑪利諾中文學校課後班課程，在校活動期間由全體老師負起督導及教育之責，但希望能督促並提醒遵守以下事項：  1. 學生在校期間行為應遵守學校規定，一切行動以安全考量為優先。  2. 學生因事不能到校請事先向班導師或辦公室請假。  3. 學生在校期間以學校老師規定的範圍活動，不得擅自離開外出。  4. 學生在校期間若欲提前或中途離開，家長請事先來電告知，並繳交提早離校切結書方得離開。(提早離校切結書請跟辦公室或老師領取填寫)  5. 不可在教室吃喝東西，不可破壞公物或亂動教室東西。  6. 在任何時間學生不可單獨停留在教室，禁止在校園內及走廊奔跑。  7. 請勿攜帶貴重物品，例如遊戲機、手機、現金及任何電子產品，一旦遺失學校不負任何損失賠償責任。手機在上課時間務必關機。  8. 學生在校期間如有任何不適，請立即告知其任課老師及辦公室，以便在第一時間做出緊急處理。  9. 學生在校活動期間必須遵守學校所有規定，若因不遵守規則而發生意外，家長必須自行負責。Given the student attends the Chinese School of San Marino’s After School Program, while attending and participating in the Program, CSSM instructors are responsible for their education. We hope parents and guardians will remind their students of the following:  1. Students are to abide by school conduct policies and regulations while in our programs, and are to conduct themselves in a manner that puts safety first.  2. If your children will be absent, please contact their instructor(s) or School Office (626) 796-5190, info@ccsm.org in advance.  3. Students are to remain on-site and not to depart the premises on their own.  4. If students need to leave early, parents/guardians are to first inform the school by phone call (not text message), and sign an early dismissal form (early dismissal forms are available from the CSSM office).  5. No eating or drinking in the classroom. Do not damage school property or move any equipment in the classroom.  6. Students need to proceed to their assigned classrooms under adequate adult supervision. Running through the campus and hallways is prohibited.  7. Please do not bring expensive items, such as gaming systems, cash and any technical equipment. School will not be responsible for loss or damage to the property. Please turn off the cell phone during the class. 8. If students are feeling unwell, please have them immediately inform their instructors and/or safety teacher, so that instructors can take necessary precautions.  9. Students are to follow school rules and regulations. Should any injury occur because students violate conduct, parents/guardians are to bear responsibility.   *
Required
Electronic Signature/Date 電子簽名/日期 * *
以下的電子簽名及日期聖瑪利諾中文學校視為等同手寫簽名的效力，我確認所有提供的訊息都是正確無誤的。 The electronic signature below and its related fields are treated by Chinese School of San Marino like a handwritten signature on the paper form. I affirm that all the information provided is true and correct to the best of my knowledge.
請您提供其他的意見。  Any other comments and/or questions?
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