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 Registration Form | NYC After School Enrichment Classes (Spring 2015)
! HudsonWay Immersion School Student
! Non-HudsonWay Immersion School Student
Student Information
Name: __________________________________________ Gender: ____ Date of birth: ___/____/____
Current grade: _______ Age: _____ Current school name & address: ____________________________
Parent Information
Name of Parent/Guardian #1: _________________________ Relationship to child: __________________
Cell phone number: _______________________ Email: ________________________________________
Name of Parent/Guardian #2: _________________________ Relationship to child: __________________
Cell phone number: _______________________ Email: ________________________________________
Class
Schedule
Chess
(K & Elementary grade levels)
Min. 4 students, max. 14 students
4:00-5:15 PM
Drama/Theater Class
(Preschool level; 3-4 year olds)
Min. 6 students, max 12 students
3:45-4:30 PM
Robotics
(K and Elementary grade levels)
Min. 8 students, max. 12 students
4:00-5:30 PM
Session Fee
Sign me up!
$325
(10 sessions)
☐
$325
(10 sessions)
☐
$550
(10 sessions)
☐
Mon. April 27, Mon. May 4,
Mon. May 11, Wed. May 13,
Mon. May 18, Wed. May 20,
Wed. May 27, Mon. June 1,
Wed. June 3, Mon. June 8
Mon. April 13, Mon. April 20,
Mon. April 27, Mon. May 4,
Mon. May 11, Mon. May 18,
Mon. June 1, Mon. June 8,
Wed. June 10, Thurs. June 11
Tuesdays and Thursdays,
May 5th – June 4th
Registration Fee
(Non-HudsonWay Immmersion School Students only)
TOTAL
175 Riverside Boulevard New York, NY 10069 • (212) 787-­‐‑8088 • www.hwis.org $25
Program Information:
• Class needs to meet the minimum number of students required. If you enroll and there are not enough
students, we will return your fee.
• Class offerings are subject to change per trimester.
• Please make checks payable to HudsonWay Immersion School and please send along with your
registration form.
• Registration is first come, first served.
• A completed registration form and full payment are required to reserve your child’s spot.
Allergies - (Required, non-HudsonWay Immersion School students)
If your child has any allergies or health concerns that we should be made aware of, please list them here:
Medical Authorization - (Required, non-HudsonWay Immersion School students)
In case of emergency, give names of persons who can be called and are authorized to pick up your child if we cannot
reach a parent.
Emergency contact name: ___________________________________ Phone: ____________________
Relationship to child: ____________________________
Photo/Video Permission - (Required, non-HudsonWay Immersion School students)
When classes are in session, there are times when pictures or videos may be taken to showcase an activity or an
event. Photos or videos may be used by program vendors, internally, or in school marketing materials including our
school’s website and other school’s social media sites.
Yes, I give my permission to use pictures or videos of my child taken at classes, including on the internet and in
printed materials.
No, I do not give my permission to use pictures or videos of my child taken at classes.
Pick-up/Drop-off Authorization (other than parent)
(Required, non-HudsonWay Immersion School students)
Name: ______________________________________ Phone: _________________________
Relationship to child: __________________________
This authorization applies as follow:
_____Pick up
This authorized person will perform this function:
_____Drop off
_____Sometimes
_____Always
This authorization will remain in effect until canceled by me
_______________________________________________________ (Signature)
Parent Signature: ____________________________________
Date: ______________
175 Riverside Boulevard New York, NY 10069 • (212) 787-­‐‑8088 • www.hwis.org