Mencius Chinese Academy - Best Chinese Classes in Phoenix

Mencius Chinese Academy
Chinese Immersion Summer Camp Registration Form
Website: www.menciusacademy.org
Phone: (480)206-3469/Email: www.menciusacademy.org/contact

Student Information:
Name:___________________________________________________

Date of Birth:_____________ Grade Level:________ School:_________________

Parent Information:
Mother’s Name: _________________E-Mail:______________________________

Address:________________________________________________________

Home Phone: _____________ Cell Phone: _______________Work Phone: ________________

Father’s Name: ___________________ E-Mail:___________________________

Address:________________________________________________________

Home Phone: _____________ Cell Phone: _______________Work Phone: ________________

Emergency Contact:
Name: ___________________________________________________

Relationship to Child:_______________________________________________

Address:_________________________________________________________

Home Phone: _____________ Cell Phone: _______________Work Phone: ________________

Camp Session (Circle One) I II III Camp Start Date:__________________

Select One: ___Full Day ___Half Day Subtotal: $______________________

Extended Hours: Morning or/and Afternoon Subtotal: $______________________

Friday Lunch: ___ X $7 = $_________; Material Fee $15; Subtotal: $______________________

Total Payment Amount:___________

Please make check payable to: Mencius Chinese Academy
Please mail the check to: 8776 E. Shea Blvd. Suite B3A-538, Scottsdale, AZ 85260-6629