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Czech and Slovak School of Pittsburgh Student Enrollment Form - 2019/2020
*
Indicates required field
Interested in classes for:
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Czech language
Slovak language
Student’s name
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First
Last
Date of birth (mm/dd/yyyy)
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Gender
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If more than one student from the family is attending, please fill here:
2nd Student's name:
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First
Last
2nd Date of birth
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2nd Gender
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3rd Student's name
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First
Last
3rd Date of birth
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3rd Gender
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Student's address
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Language level
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Speaks fluently, understands all age appropriate
Understands all age appropriate, does not speak
Understands some, does not speak
Understands very little to none, does not speak
Mother's name
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First
Last
Mother's cell phone number
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Mother's email
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Mother's home phone
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Mother's address (only if different from above)
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Father's name
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First
Last
Father's cell phone number
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Father's email
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Father's home phone
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Father's address (only if different from above)
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My child may be released to the person(s) signing this agreement and/or to the following designated person(s). Please list name, Address and Relationship
Name and Relationship - 1st designated person
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Address - 1st designated person
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Name and Relationship - 2nd designated person
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Address - 2nd designated person
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Name and Relationship - 3rd designated person
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Address - 3rd designated person
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Persons to contact in case of emergency, when parents cannot be reached. Enter Name, Relationship, Home Phone number and Cell Phone number
Name and Relationship - 1st emergency
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Home # - 1st emergency
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Cell # - 1st emergency
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Name and Relationship - 2nd emergency
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Home # - 2nd emergency
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Cell # - 2nd emergency
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Medical information
Physicians's name
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Physician's phone number
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Insurance Policy / Group #
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Does your child suffer from any allergies (food, beverages, medication, insect bites/stings)?
Allergies
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List any illnesses, injuries, hospitalizations within last 12 months:
Illnesses
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List any medications your child is currently taking:
Medications
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Does your child have any medical condition we should be aware of?
Medical condition
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Does your child have any special needs or any behavior we should be aware of?
Special needs
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Provide any additional information that will help us get to know and understand your child. What language is primarily spoken at home (with mother/with father)? Are there any opportunities for your child to speak Czech/Slovak outside of the classroom (grandparents, friends, etc.)? What language does your child prefer? Any other comments or information that you believe our teachers should know? What do you expect your child to gain from attending the school?
Additional comments
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Tuition and classes
Tuition for each semester is $80 or $100, depending on your child's age. For detailed information about classes and payments, please visit our
information page
.
Consent for emergency medical assistance
Click
HERE
to review the policy and initial:
Parent's initial:
*
Right to use images:
Click
HERE
to review the policy and initial:
Right to use images
*
Yes
No
Parent's initial:
*
Sharing contact information
Click
HERE
to review the policy and initial:
Share our contact information:
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Yes
No
Parent's initial:
*
Nondiscriminatory policy
Click
HERE
to review the policy and initial:
Parent's initial
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By writing my name to the box below, I agree with the Waiver of Liability (click
HERE
to review)and I acknowledge that I have read and understood this form in full for the purpose of registering my child/children at
the Czech and Slovak School of Pittsburgh
. I agree to abide by the rules and regulations of the Czech and Slovak School of Pittsburgh and that my child/children will do the same.
Parent's signature:
*
Please click the button bellow to submit your registration.
If any of the required fields are missing or any field is entered incorrectly, you need to correct the highlighted fields before a successful submission.
A message will appear when your online application has been successfully submitted.
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