Name of Child:  

Date of Birth:               

Parent Name: 

Address:    

City:  Zip:              

Email: 

Phone number: 

CELLPHONE NUMBERS FOR BOTH PARENTS: 

FOOD ALLERGIES: 

Please list any other languages your child speaks or has been exposed to (by grandparents for example - or trips to a country that speaks the language) - please also tell us if they have studied this language before. Also - if they have specific challenges in their current class - please explain.

Anything we should know about your child - how they learn, are they shy, any disabilities?  

No schedule posted for a language in which you are interested?  Please tell us what you want to see:

Please submit this form.  A confirmation page will appear.  Print it out and mail it with your check payable to:  Atkins International.  65 Old Highway 22, Suite 2, Clinton, NJ  08809  - If you prefer to pay with a credit card, click this box and we will email you an invoice that you can pay securely online. 

I WANT TO PAY WITH A CREDIT CARD! (if you mark this, we will send you an email with a secure link to pay online)

$400.00 for 20 1-hour sessions (January to June) - 5% discount for siblings

Total Amount to Be Paid: 

When we receive your payment, we will send you a receipt and confirm the start date of the program.  We reserve the right to cancel a program due to low enrollment.  Missed classes cannot be made up and are not refundable.  You will receive a confirmation via mail.