2010 信心兒童夏令營報名表 2010 Faith Summer Day Camp Registration Form 英文姓名 English Name 中文姓名 Chinese Name 性別 Sex 年齡 Age 生日 Date of Birth 年級 Grade 1. _____________, ________________ last name 姓 first name 名字 _______________ ____ ____ ____/____/_____ _____ 2. _____________, ________________ last name 姓 first name 名字 _______________ ____ ____ ____/____/_____ _____ 3. _____________, ________________ last name 姓 first name 名字 _______________ ____ ____ ____/____/_____ _____ 1. 地址 Address: ________________________________City: _____________State: _____Zip: ________ 2. 電話 Telephone#: 住家(Home): ____________________ 辦公室(Office): ____________________ 3. 緊急連絡人姓名、電話 In case of emergency, contact person & phone #: 姓名 Name: ___________________住家電話(H)___________________ 手機(C) ___________________ 4. 需要 ESL 教學嗎 Need ESL?: 否 (No) 是 (Yes) 5. 所屬教會 Church Affiliation:__________________________________ 6. 在家使用語言 Language Used at Home: 英語(English) 國語(Mandarin) 粵語(Cantonese) 溫州語(Wenzhou) 福州語(Fuzhou) 其它(Others): _______________________________ 7. 是否有任何敏感 Any Allergies? 沒有 No 有 Yes: ______________________________________ 8. 家庭醫生姓名 Family Doctor‘s Name: ______________________電話 Tel: ________________________ 9. 上課日期 Weeks Registered: 自(from) ____/____ 至(to) ____/____(第____週 ~ 第____週 // wk____ ~ wk____) 二週(2 weeks) 四週(4 weeks) 六週(6 weeks) 八週(8 weeks) 其他( _____週) 10.需要車輛接送嗎 Transportation Needed?否 No 是 Yes 接來 pick up 送回 send back 車輛接送只限某些區域。如是屬其他區域,請留下電話聯絡 (Limited Areas, Leave Tel# if needed) Flushing / College Point / Whitestone - 11354, 11355, 11356, 11357, 11358, 11365, 11366, 11367 Bayside - 11360, 11361, 11362, 11364 Forest Hills – 11374, 11375 11.需要早到或晚走嗎 Early Arrival or Late Pickup? 否 No 是 Yes : 早到 Early arrival 晚走 Late pickup 12.可以接我孩子之人的名字 Names that can pick up my child :____________________________________________ 13.如何得知本兒童夏令營 How do you know about this summer camp? 報紙 (Newspaper) 廣播 (Radio) 朋友介紹 (Friends) 其他 (Others) _________________ 此欄由工作人員填寫 ( Office Use Only) 14. 付費 (Payment):$_______________ 現金 (Cash) ____________ 支票 (Check) # __________________ 15. 接收註冊表之人姓名 (Recipient of this registration & payment):__________________ 日期(Date): We, _____________________( Parent’s name 家長姓名) do hereby grant permission for ____________________ (Student’s Name 學生姓名) to attend Faith Bible Church Community Center School sponsored by FAITH BIBLE Inc. and take full responsibility if anything should happen to my child(ren). I hereby absolve FAITH BIBLE INC. of any legal responsibility. __________________________________ __________________ 家長簽名 Parent‘s or Guardian’s Signature 日期 Date 我已清楚明白並接受信心兒童夏令營退費和請假規則 I fully understand and accept the refund policy and absent policy of Faith Summer Day Camp. __________________________________ __________________ 家長簽名 Parent‘s or Guardian’s Signature 日期 Date ………………………………………………………………………………………………………………………………………………………………………………………. 日期 Date:7/6/2010 – 8/27/2010 週一至週五,一共八週 (Monday through Friday, 8 weeks in total) 時間 Time: 9:00 A.M. - 5:00 P.M. 招收學生年齡 Student‘s Age: 4-14 註冊費 Registration Fee: $50 (恕不退還 nonrefundable, 包括外出旅行保險費 including trip insurance) 學費 Tuition Fee: 包括英文閱讀、文法、數學教材、外出旅行門票、夏令營 T 恤、午餐及午後點心 (including materials of reading, math, & grammar, T shirt, trips, lunch and afternoon snacks) (1) 八週(8 weeks) $730 (2) 六週(6 weeks) $630 (3) 四週(4 weeks) $530 (4) 二週(2 weeks) $430 同一家庭特價 Same Family Member Discount: 同一家庭第二個孩子減免$100,第三個孩子半價 (Within the same family, 2 nd child $100 less, 3 rd child half price) 五月底以前註冊,每個孩子再各減免$50(Registered before May 31st, additional $50 discount each child) 提供早到或晚走的服務 Early Arrival or Late Pick-Up Available: $1/半小時 ($1per 1/2 hr.) 車費 Transportation Fee: 每單趟 $5 ($5 one single trip) 信心兒童夏令營退費規則 Faith Summer Day Camp Refund Policy: 1. 註冊費一旦報名之後恕不退還。After register the program, registration fee will not be refund. 2. 學生註冊後,6/20 以前因故申請退出夏令營,學費全額退還,6/20 以後申請者,將退還剩餘學費 的 80%。We will refund tuition 100% if the withdrawal applied before 6/20. After 6/20, the refund is 80% of the remaining tuition for all withdrawal. 3. 若註冊後申請退出,本學校將會退還剩餘的車費。Faith Summer Day Camp will refund the entire remaining transportation fee for all withdrawal after registration. 報名請洽 Registration: 信心聖經會 FAITH BIBLE INC. 133-20 41st Ave. Flushing, NY 11355 Tel.: (718)961-9355 Fax: (718)886-8676 支票抬頭請寫 Please make check payable to: FAITH BIBLE INC.