REGISTRATION

Parent/Guardian's Name
Child/Children(s) Name
Child/Children(s) Ages & Birthdates
Phone Number
Home Address
City, State Zip
E-Mail Address
How Did You Meet or Hear Of Us?
Special Interests or Needs of Children
Choice One Session Day and Time
Choice Two Session Day and Time

Payment Amount: $250 for 10 week program, $225 for returning students.

Please help us with scheduling by indicating a more desirable time for the future

Once submitting form, please make checks payable to:

The American Sign Language Connection
1420 Lakeside Drive
Wantagh, NY 11793