2015–2016非PS184學生課後班報名表-SWAN.PDFVIP

Shuang Wen Academy Network For Office Use Only (PS/ NPS) PS 184 M. Registration Date received (1st Payment): ___________ ASP Sep 2015 – June 2016 Received by: ________________ Return to SWAN Office, Rm 106 Date received (2nd Payment): __________ Received by: ________________ Date received (3rd Payment): __________ Received by: ________________ Student Name: ________Chinese Name:______________ Current Grade and Class # in 2014-2015: ______ 2015-2016 Grade: _______________ Parent/Guardian Information (Please Print) ( ) Mother ( ) Father ( ) Legal Guardian First Name:__________________________ Last Name:______________________ Street Address:________________________ Apt.: _________ City:________________________ State:_______ Zip Code:_________________ Home Phone: (______)___________________ Email:________________________________ Mobile Phone: (______)___________________ st nd rd th □ Check if you are registering for the English Reading Support Program (1 , 2 , 3 and 4 Grade only). You will not receive Chinese language instruction when you select this program. SWAN Afterschool is subjected to cancellation if minimum enrollment is not met. We will not