Children's Italian Language Classes, 2022 - 2023 - Elmwood Park Tuition Form

Elmwood Park Recreation Center

Parent/Guardian Information

First Name *

Last Name *

Relationship *

Email Address *

Phone Number *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Emergency Contact Information

Contact 1: First & Last Name *

Contact 1: Relationship *

Contact 1: Cell Phone *

Contact 1: Email Address *

Student Information

Number of Students *OneTwoThreeFour

Student 1

Student 1: First Name *

Student 1: Last Name *

Student 1: Class Level *

Student 1: Date of Birth *

Student 1: Years in Italian *

Student 1: Current Grade *

Student 1: Allergies and Medical Conditions

Does {name-5} (Student 1) have any allergies or any medical issues Casa Italia needs to be aware of? If yes, please list allergies and /or medical issues.

Student 1: Allergies *YesNo

Student 1: Allergy Description0 / 180

Student 1: Medical Issue? *YesNo

Student 1: Medical Condition Info.0 / 180

Student 1: Message0 / 180

Student 2

Student 2: First Name *

Student 2: Last Name *

Student 2: Class Level *

Student 2: Date of Birth *

Student 2: Years in Italian *

Student 2: Current Grade *

Student 2: Allergies and Medical Conditions

Does {name-9} (Student 2) have any allergies or any medical issues Casa Italia needs to be aware of? If yes, please list allergies and /or medical issues.

Student 2: Allergies *YesNo

Student 2: Allergy Description0 / 180

Student 2: Medical Issue? *YesNo

Student 2: Medical Condition List0 / 180

Student 2: Notes0 / 180

Student 3

Student 3: First Name *

Student 3: Last Name *

Student 3: Class Level *

Student 3: Date of Birth *

Student 3: Years in Italian *

Student 3: Current Grade *

Student 3: Allergies and Medical Conditions

Does {name-13} (Student 3) have any allergies or any medical issues Casa Italia needs to be aware of? If yes, please list allergies and /or medical issues.

Student 3: Allergies *YesNo

Student 3: Allergy Description0 / 180

Student 3: Medical Issue? *YesNo

Student 3: Medical Condition List0 / 180

Student 3: Notes0 / 180

Student 4

Student 4: First Name *

Student 4: Last Name *

Student 4: Class Level *

Student 4: Date of Birth *

Student 4: Years in Italian *

Student 4: Current Grade *

Student 4: Allergies and Medical Conditions

Does {name-8} (Student 4) have any allergies or any medical issues Casa Italia needs to be aware of? If yes, please list allergies and /or medical issues.

Student 4: Allergies *YesNo

Student 4: Allergy Description0 / 180

Student 4: Medical Issue? *YesNo

Student 4: Medical Condition List0 / 180

Student 4: Message0 / 180

PHOTOS: If any photos are taken of your child(ren) participating in our Italian language program, do you allow Casa Italia, Inc, DBA Italian Cultural Center, to use photos for promotional reasons? * I Allow Casa Italia To Take Pictures Of My Child(ren) For Promotional Reasons.No

REFUND POLICY: A full tuition refund of 100% will be given if a student withdraws before the first scheduled class. A partial refund of 80% will be given if a student withdraws between the first and second scheduled classes. NO refunds will be given after the second scheduled class. To cancel or change the registration, you may call 708-345-5933 or email your request to info@casaitaliachicago.org. *

I have read and understand the Cancellation Policy. If you have questions call 708-345-5933.

TOTAL

Payment MethodCredit Card / Debit Card / PayPalCheck by Mail (Due Date: August 31, 2022) Casa Italia, 3800 W. Division St., Stone Park, IL 60165

Children’s Italian Language Classes, 2022 – 2023 – Elmwood Park Tuition Form