1345 Bush Street, San Francisco CA 94109
REGISTRATION FORM CNED 2015
Provided by the Alliance Francaise de San Francisco (AFSF)
Grade levels:
o Grande Section maternelle
o CP
o CE1
o CE2
o CM1
o CM2.
o Sixième
1. STUDENT INFORMATION
Last name:_______________________
First name:___________________________
Gender:__________________ Date of birth:_____________(MM/DD/YYYY)
Address:________________________________________________________________
City:___________________________ Zip code:__________________________
Health Information (allergies, injuries…):____________________________________
2. PARENT OR LEGAL GUARDIAN INFORMATION
1) Relationship with the student:___________________________________
Last name: ______________________ First name:________________________
Address (if different): ______________________________________________
City: _______________________________ Zip code:___________________
Email: _________________________ Phone number: (_____)_____________
2) Relationship with the student:___________________________________
Last name: ______________________ First name:________________________
Address (if different): ______________________________________________
City: _______________________________ Zip code:___________________
Email: _________________________ Phone number: (_____)______________
3. PERSONS AUTHORIZED TO PICK UP STUDENT
1-Name:_______________________ Relationship to child:______________________
Contact number:________________ Emergency number:_______________________
2-Name:_______________________ Relationship to child:______________________
Contact number:________________ Emergency Number:_______________________
3-Name:_____________________ Relationship to child:________________________
Contact number:______________ Emergency number: _________________________
I agree that my child will be picked up on time.
4. PICTURE
I authorize/do not authorize my child’s picture to be used for the Alliance
Française de San Francisco’s marketing opportunities with the understanding that my
child’s name not be used.
A WRITTEN NOTE SIGNED BY MYSELF WILL NOTIFY THE
INSTRUCTOR OF ANY CHANGES
5. TERMS AND CONDITIONS
§ I, ___________________, parent/legal guardian of ________________ agree to
the following and release and hold AFSF unaccountable from any liability
therefrom.
My child will be released from the classroom at the end of the class to the following
designated responsible adults who have met the instructor before the start of classes
and have identified themselves as such:
§ I give AFSF permission to seek medical treatment for my child in case of
emergency and if AFSF has not been able to contact me. I accept full
responsibility for the cost of treatment for any injury that may be suffered by my
child while taking part in CNED. I hereby assume all risk and hold AFSF and any
instructors, harmless, from any liability, claim or injury, damage or loss of property
that may occur in connection with this enrollment.
§ AFSF reserves the right to cancel and/or change the schedule, location, or time of
any session at any time without liability. AFSF attendees are responsible for their
own actions during after-school class sessions. AFSF reserves the right to remove
attendees from any AFSF class sessions for unacceptable behavior, at AFSF’s or
its agents’ sole discretion. AFSF attendees will be released to their parent or
guardian. The parent or guardian must present identification. AFSF is not
responsible for any damage to or loss of personal property that arises from or is
related to an individual’s participation in CNED. The parent or guardian
acknowledges and agrees that he/she will be liable for any property damage or
personal injury claims arising from or related to the acts of his/her child during
AFSF CNED sessions.
I have read the above and agree to the terms.
________________________________
Signature and date
_____________________________
Name & relationship to child