Dr. Lang’s Chinese Bilingual School

Dunwoody Branch

4675 North Shallowford Rd. Suite 202, Atlanta, GA 30338

Tel: 678-887-2279; Office & Fax: 678-473-6135

www.langcbs.com Email: nancy@aeiuo.com

After School Chinese Classes Application Form

School Year Registration Fee: $30 per student $40/2-children family $ 45 (3-children family)

Tuition Payment Plan ’ Weekly ’ Every 4 weeks

Number of Classes per week to attend ’ 2-day classes ’ 3-day classes ’ 4-day classes ’ 5-day classes

Choose Daily Class Time ’ 3:10 - 4:20 ’ 4:30-5:40

Chinese name _____________________ English name ____________________________

Age：_________ Current Grade：______________

Current School Name：_____________________ County: __________________

School Release Time: ______________ Language spoken at home: ____________

Home Address ：__________________________________________

Home phone ：___________ Father’s Name: ___________ Mother’s Name: _________

Mom’s Cell: __________________；Dad’s Cell :____________________

Email Address: ________________________________

Emergency Contact : _____________________ Phone #：___________________

Allergies and other health concerns：____________________________________

Insurance Company：________________________

Parent/Guardian Signature：________________ Date of Application：__________