Children's Italian Language Classes, 2023 - 2024 - 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: Refunds for classes are based on specific dates of withdrawal. 1. 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. 2. Textbooks for children’s and adults classes are not sold by Casa Italia and are not returnable or refundable. 3. Any applicable tuition discounts will not be given at the time of registration. They will be applied retroactively once the tuition payment has been received.. 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 - Casa Italia, 3800 W. Division St., Stone Park, IL 60165

Children’s Italian Language Classes, 2023 – 2024 – Elmwood Park Tuition Form