Flyer 3 - Franco-American School of New York

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Payment Form Child’s Name: PAYMENT: ⁪ Amex ⁪ Discover ⁪ Visa ⁪ MasterCard ⁪ Check Name on Card: ________________________________________ Card Number: __________________________________ Expiration Date: ______ Signature: __________________ Security ID (last 3 digits on back of card): ______ Please mail registration form with payment (checks payable to FASNY) to: FASNY After-School Program ATTN: Agnès Tounkara, Fall Vacation Program 2010 525 Fenimore Road Mamaroneck, NY 10543 Important: No refunds will be granted after the starting date of the activity, unless the program is canceled for low enrollment. No discount will be given for missed classes. Program is subject to change. 3
Emergency Form Child’s name: Parent/Guardian 1: ___________________________ Address: _____________________________________ Phone #: _____________________________________ Cell #: _______________________________________ E-mail: _______________________________________ Parent/Guardian 2: ____________________________ Address: ______________________________________ Phone #: ______________________________________ Cell #: ________________________________________ E-mail: ________________________________________ Emergency contacts: Name: _________________________________________ Phone #: _______________________________________ Cell #: _________________________________________ Relation to child: ________________________________ Name: _________________________________________ Phone #: _______________________________________ Cell #:_________________________________________ Relation to child: ________________________________ 4
Page 1 and 2: Fall 2010 Vacation Program October
Page 3: Registration Form Child’s Name: D

Flyer 3 - Franco-American School of New York

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