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Building Kidz/Cool & Classic PAC Registration form
SUMMER ENRICHMENT June 14th-Aug 20th
Student First and Last Name__________________________________________________ Birth Date____________ Age______ Interests___________/____________/____________ Mother’s First & Last Name __________________________Tel #___________________ Father’s First & Last Name __________________________ Tel #___________________ Address:_____________________________City_____________Zip______________________ Emergency Contact Name ____________________________ Tel #
COURSE SELECTION 2010
Musical Theatre Music Spanish Creative Arts
Tech Arts Social Dancing Worldwide Dancing
First Choice Second Choice Cost Paid Week 1 __________________________ __________________________ $300 __________ Week 2 __________________________ __________________________ $300 __________ Week 3 __________________________ __________________________ $300 __________ Week 4 __________________________ __________________________ $300 __________
2 week _________________________ __________________________ $550 __________ 4 week __________________________ __________________________ $1050 __________
8 week __________________________ __________________________ $2000 __________
LUNCH, EARLY & AFTER CARE Cost per week . Lunch & Snack 12:00 – 12:30 PM $50 $__________ . Early Care 8:00 – 9:00 AM $30 $__________ . After Care 3:30 – 5:00 PM $50 $__________ . Early & After Care $75 $__________ . Registration Fee (One time only) $50 $__________ (July 4th week 20% off) $-60
TOTAL $__________ Check #_________ Cash_________
REFUND POLICY: If you cancel any period or withdraw completely at any time before the start of the summer session, you will be refunded 100% of the tuition paid minus a $50 registration/processing fee. If you cancel any period or withdraw completely at any time after the start of the summer session, no refund is provided.
Food allergies (If applied for Lunch & Snack)
I hereby give permission to any member of the staff of Building Kidz to authorize any diagnostic tests, treatment, or operative procedures as may be deemed necessary for my son's/ daughter's urgent medical need.
Insurance name _____________ Insurance card # ________________ Primary Physician __________________
*Photo release permission
I give permission for my child’s photograph to be used by Building Kidz Summer Enrichment/Summer Camps for Web pages, advertising and/or promotional materials. I understand that my child’s last name will not be used.
. Yes. No Parent signature:______________________________________________ Date:__________________________
Building Kidz School Web: www.coolnclassicpac.com www.buildingkidzschool.com Email: Buildingkidz07.com 1950 Elkhorn Ct San Mateo Ca 94403 Tel: 650-212-5439 Fax: 650-212-5020
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Summer Program 
