MIA Learning Registration Form

Registration Form - MIA Learning Center

Welcome!
We are Multicultural Immersion Academy, a Learning Center with an innovative approach to teaching and learning Spanish as a second language. We use creative pedagogical techniques and believe that the path to acquiring a second language is also the way to genuinely develop essential human skills such as critical thinking, creativity, communication, and collaboration. We offer three programs:

Out of School Hours .
Private Tutoring Class.
Seasonal Activities

All programs support the development of motor, language and social skills.You can sign up either for a full program or select those days that are most convenient for you and your child (children). To ensure your child's spot please, check the following instructions.

INSTRUCTIONS

1. Download MIA Parent Agreement.pdf

2. Complete the following Form and Submit it

A. PRIMARY PARENT / GUARDIAN

First Name*

Last Name*

Address*

Contact Number*

Email*

B. SECONDARY PARENT / GUARDIAN

First Name*

Last Name*

Address*

Contact Number*

Email*

C. ADDITIONAL & EMERGENCY CONTACTS

Please list two people authorized to pickup the child (they should present a photo ID at pick up time)

Email Addresses

Phone Numbers

Emergency Contact Name*

Emergency Contact Phone Number*

D. CHILD INFORMATION

Child First Name*

Child Last Name*

Date of Birth*

Gender*

Female Male

List Allergies*

Medication*

Child's insurance carrier and number ** All students are required to have insurance

E. PROGRAMS INFORMATION

Select the program(s) you are applying for*

Out of School Hours (OOSH)
Private Tutoring Class (PTC)
Seasonal Activity (Camps,PNO)

F. PERMISSION TO USE PHOTOGRAPH

I agree that MIA may use such photographs of my child for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and website content*

I grant MIA, the right to take photographs of my child I do not grant MIA, the right to take photographs of my child