| Registrating for: * |
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| Class Types: * |
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| Class Location: |
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| School Name: |
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| Age: * |
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| Gender: * |
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| First Name: * |
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| Last Name: * |
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| Address Street 1: * |
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| Address Street 2: |
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| City: * |
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| Zip Code: * |
(5 digits) |
| State: * |
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| Daytime Phone: * |
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| Evening Phone: |
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| Email: * |
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| How is your Chinese skills: * |
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| Chinese Heritage: * |
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| Disclaim: |
I agree to indemnify and hold unaccountable the Da Ke American Chinese Culture Center, director,officers, teachers, and agents from any liability, claims, or action arising out of participation in school activities or any other actions. In the event that parents or the designated physician cannot be reached, I authorize the school to use its discretion to secure medical aid. Also I agree to notify the school of any changes of information on this form immediately.
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