NEW STUDENT INFO REQUEST FORM *

PLEASE NOTE: This form should only be filled out upon request by a CCBG administrator OR as an additional form submitted with an enrollment form. We respect your privacy. All information provided are strictly confidential and are only used for CCBG's administrative purposes. We do not share, spam or solicit your or your child's information.

Yes, I have been contacted by a CCBG administrator to provide the following information about my child(ren).

PRIMARY Parent's (Your) Full Name *

First Name

Last Name

PRIMARY Parent's (Your) Phone Number *

(###)

###

####

PRIMARY Parent's (Your) Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SECONDARY Parent's Full Name *

Please enter the name of a secondary parent/guardian that is not the primary parent (you). If not applicable, please enter NA.

First Name

Last Name

>>>>>>>(1st) Child's Full Name *

First Name

Last Name

(1st) Child's Date of Birth *

MM

DD

YYYY

(1st) Child's Gender *

Male

Female

Other

Does your (1st) child have any allergies? *

Food, medical, environmental, etc. Please indicate on the space below.

None — My (1st) child does not have a known allergy.

Yes — My (1st) child has the allergy condition listed below.

>>>>>>>(2nd) Child's Full Name

First Name

Last Name

(2nd) Child's Date of Birth

MM

DD

YYYY

(2nd) Child's Gender

Male

Female

Other

Does your (2nd) child have any allergies?

Food, medical, environmental, etc. Please indicate on the space below.

None — My (2nd) child does not have a known allergy.

Yes — My (2nd) child has the allergy condition listed below.

>>>>>>>(3rd) Child's Full Name

First Name

Last Name

(3rd) Child's Date of Birth

MM

DD

YYYY

(3rd) Child's Gender

Male

Female

Other

Does your (3rd) child have any allergies?

Food, medical, environmental, etc. Please indicate on the space below.

None — My (3rd) child does not have a known allergy.

Yes — My (3rd) child has the allergy condition listed below.

PART 3 — EMERGENCY CONTACT & PICK-UP, DROP-OFF *

By default, our program contacts the PRIMARY parent/guardian of a student in case of an emergency, and we contact the SECONDARY parent/guardian if the primary parent cannot be reached. If you would like to leave a third emergency contact OR a different emergency contact than the primary and secondary parents/guardians, please do so in the space provided below.

My child(ren) is/are enrolled in an Online Program only. (Do not need to provide any info for this part, proceed to PART 4.)

My child(ren) is/are currently enrolled in an Online Program, but MAY switch to an On-Site Program at some point. (Please provide drop-off/pickup info if necessary.)

My child(ren) is/are enrolled in an On-Site program. (Please provide drop-off/pickup info if necessary.)

PART 4 — CONSENT & WAIVER AGREEMENT *

(In the event that your child(ren) is/are no longer enrolled with us, this consent and waiver agreement will be automatically nullified.) PHOTOS & VIDEOS: Occasionally here at CCBG, we take photos or videos of our teachers and students engaging in class and activities. These photo and video documentaries are used for the purposes of sharing the learning experiences of our students with their families, or used within our program for teacher training purposes, or used on our website. In all cases, no names are identified to the public without parents’ consent. RECORDS & INFO: We stride to improve our teaching methods, curriculum and family support quality, therefore, our program has added a research function to help us improve by understanding more about our students. We will use existing student academic records, including performance charts, writing samples, language background information, as well as performance records on tasks to identify factors that contribute to efficient Chinese language learning. When such data analyses are conducted, all personal information are made anonymous and will only be identified by a case number. HOUSE RULE POLICY: In events when the health and safety of the CCBG community face potential risks, CCBG reserves the right to set forth house rules. The rules may concern the format of the classes, regulations of on-site class qualifications and indoor space usage. LOCAL FIELD TRIPS (Applies to On-Site Students Only): In addition to our curriculum, to better the learning experience for our students, the teachers sometimes may bring students outside of our facilities to learn and use Mandarin in a real-life contexts (such as nearby bakeries, stores or parks). MATERIAL COPYRIGHTS: All of CCBG’s materials are under their applicable copyrights and are subjected to copyright laws. Our materials are strictly reserved for the private use of individuals, currently or previously enrolled in our programs, for the sole purpose of their learning. Therefore, we ask that students, families and participants of our programs in possession of any materials produced by CCBG to not, and shall not reproduce, photocopy, or photograph such materials with the intention of distribution. Please select below to consent that you have read, understood and agree to CCBG's Consent & Waiver Agreement.

I confirm that I have read and understood the above agreement and granting CCBG the permission for photography, video recording, usage of research data, as well as taking my child for out-of-program-space field trips. To which, I also understand the risks involved when being in the general urban environment and release CCBG from all liabilities. I also confirm that I have read the Materials Copyrights section above and understood the implications stated and give my agreement to CCBG to respect and comply with the copyrights laws for all materials I receive from CCBG.