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Personal

First Name: Last Name:
Gender: Birthdate:
Address: City:
Province: Postal Code:
Phone: Cell:
(optional)
Country: Passport #:
Age:
Email:
Medical Alert : (optional)
Current School Grade (Form) Level:

English Class (Monday to Friday 9 – 12 noon)

Select one English Class Registration Fee
2-week, July 4 to July 15, 2011 $385
2-week, July 18 to July 19, 2011 $385
2-week, August 2 to August 12, 2011 $385
4-week, July 4 to July 29, 2011 $685
4-week, July 18 to August 12, 2011 $685
6-week, July 4 to August 12, 2011 $885

Optional Excursion (Monday to Friday 12:30 – 4 pm)

Select one or more Excursion Registration Fee
2-week, July 4 to July 15, 2011 $685
2-week, July 18 to July 29, 2011 $685
2-week, August 2 to August 12, 2011 $685

Note: Both your registration submission and your email confirmation are proof of your registration date. Date of registration is relative to Richmond, British Columbia, Canada’s time zone.

Refund Policy: 80% of fee will be refunded if student withdraws 14 calendar days prior to the start date. No refund will be issued thereafter.

Emergency Contact in Richmond
First Name: Last Name:
Address: City:
Province: Postal Code:
Daytime Phone: Cell:
(optional)
Evening Phone: Email:
Relationship:

Credit Card

Card Type: Expiry: Month

Year
Number:
3 Digit Code: (on the back of your Credit Card)
Name of Cardholder (Exactly as on Card):
I have read all the information and understand the terms and conditions, including the Withdrawal, Refunds & Transfers policy.
Permission For Child To Participate In All Scheduled Fieldtrips
I understand that as a result of participating in this program, my son/daughter’s image may appear on the Richmond District website, promotional materials or local media.
NOTE: ALL fields are mandatory unless indicated.

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