Your Language Connection: Registration Form

Name *

Email Address *

Street Address *

City *

State * Select your state. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

Daytime Phone *

Evening Phone *

Register for up to three classes/camps here. Additional classes/camps may be added in the “Other Notes” box below.

1. Class/Camp Title *

1. Day/Date *

1. Time *

2. Class/Camp Title

2. Day/Date

2. Time

3. Class/Camp Title

3. Day/Date

3. Time

If registering children, please complete the information below for up to three children.

1. Child’s Name

1. Child’s Age

1. Child’s Birthday

2. Child’s Name

2. Child’s Age

2. Child’s Birthday

3. Child’s Name

3. Child’s Age

3. Child’s Birthday

How did you hear about us? *

Other Notes

DISCLAIMER FOR CAMP REGISTRATIONS: By registering, I hereby give my child permission to attend Camps. I authorize the staff/volunteers of Kids and Cultures and Your Language Connection to take and use photographs and audio/video footage of my child as needed for their records and/or publicity programs. I hereby give permission for my child to be transported by Camp personnel or by ambulance for emergency treatment, as deemed necessary by Camp personnel. I accept all responsibility to carry insurance for injuries and health-related claims for my child. I hereby release Kids and Cultures, Your Language Connection, and the host location from all legal liability for my child.

Please use the submit button only once.