2015 SUMMER SCHOOL REGISTRATION FORM (EarlyYears)

Please return this form with your payment by May 8, 2015 for early bird discount and by May 29, 2015 for standard rate.

Student Name / Current Grade / Date of Birth (mm-dd-yy)
Home Phone / Gender / Nationality
Home Address
Parent’s Name / Email Address
Work Phone / Cell Phone
Name of School / School Address

Please indicate your selection:

Courses / Time / 6/ 22 – 8/ 7 (7 Weeks)
LAS Tiniest (Half Day)
(2- 3 yrs old) / 08:30 - 12:20 / RMB 1632 / week (Early Bird)
RMB 1813 / week (Standard)
LAS Tiniest (Full Day)
(2- 3 yrs old) / 08:30 - 15:30 / RMB2400 / week (Early Bird)
RMB 2668 / week (Standard)
LAS Minis (Half Day)
(3- 6 yrs old) / 08:30 - 12:20 / RMB 1632 / week (Early Bird)
RMB 1813 / week (Standard)
LAS Minis (Full Day)
(3- 6 yrs old) / 08:30 - 15:30 / RMB2400 / week (Early Bird)
RMB 2668 / week (Standard)

Please indicate your applying term

1st week / 2nd week / 3rd week / 4th week / 5th week / 6th week / 7th week
☐6/22 - 6/26 / ☐6/29 - 7/3 / ☐7/6 - 7/10 / ☐7/13 - 7/17 / ☐7/20 – 7/24 / ☐7/27 – 7/31 / ☐8/3 – 8/7

Lunch & Bus:Students attending the Early years program (LAS Tiniest and LAS Minis: half day / full day) must order lunch or bring a sack lunch from home.

6/ 22 – 8/ 7 (7 Weeks) / Total fees： / Remark：
Lunch /  RMB 140 / week
Bus /  RMB 275 / week
Insurance /  RMB 50 / person
 Sibling Discount (5% on tuition from 2nd child) / Please check your preferred method of payment.
First Child: (Name & Grade) ______/  Pay by cash /  Bank Transfer

The school retains the privilege to place students in class based on total enrollment, language level, and as needed.

No refunds in tuition or transportation fees will be given for withdrawal requests received after June 3, 2015.

In the event of bad weather requiring the school to close, a refund will not be issued.

I have read and hereby agree to the terms and conditions of this registration form.

Parent/Guardian’s Signature / Date

SLAS Bank Account Information:

Bank Name / First Sino Bank Hong Qiao Sub-Branch 富邦华一银行虹桥支行
Address / No.88EastRongHuaRoad,ChangningShanghai201103,P.R.C
上海市荣华东道88号201103
Phone / (86 21) 6295 1616
Account Name / Shanghai Livingston American School
上海李文斯顿美国学校
Account Number / RMBA/C50100001100004085
USDA/C50100001200004087
SWIFT / FSBCCNSH
Note / Please write your child’s English Name, Grade Level, and Summer Program on the copy of the bank voucher/remittance form and fax it to (86 21) 5218 0390 or email to for confirmation.

**Insurance Information

Please fill out Survey of Summer School Insurance Benefits that is located on the last page of Summer School Registration Form. Please turn in together with the form.

Dear Parents:

Depending on your current health and accident insurance policy for your family members, you may or may not be interested in insurance coverage for your child at Livingston American School. Please return the bottom portion of this page andinsurance feetogether with the Summer School Registration Form.

We provide the following Summer School Insurance (optional):

Summer school insurance fee: RMB 50

  • Accidental Death and dismemberment and burns benefits RMB20,000
  • Reimburse accidental outpatient or inpatient expenses RMB5,000 (Maximum limit per year)
  • Hospital Cash Benefit due to accidentDaily Allowance RMB20

(Maximum day of per hospitalization is 180 days)

*** Accredited in local hospitals only.

*** This plan includes all of the clinics in the local GradeⅡor above hospital, also include the VIP room and special clinic of Changning Center Hospital, Minhang Center Hospital and Children’s Hospital of Fudan University.

*** Hospitals NOT covered in the plan:

Shanghai United Hospital

Shanghai East International Hospital

Parkway Health

Other ISOS Hospital

*** In case of an accidental injury, a child without insurance coverage will be brought to the nearest local hospital. Expenses shall be shouldered by the parents.

This option is a group insurance. Invoice will not be issued to the parents.

Refund Policy: No refund

Please fill in this form and return together with the Summer School Registration Form.

2015 Summer School Insurance

1.______We have insurance coverage for our child and do not need additional insurance through the school.

2.______We would like to choose this option for our child.

Please write the age of the student: ______

3.______We do not have insurance for our child and do not require insurance from the school.

Please write the following statement below in your own hand.

**We don’t have coverage for our childANDwe decline the insurance coverage offered. We will not hold Shanghai Livingston American School RESPONSIBLE for an accident/injury that occurs while our child is a student at LAS.

Student’s Name:______Grade:______

Student’s Birthday (yy/mm/dd)______Student’s passport Number______

Parent’s Name:______Contact No.______

Parent’s Signature:______Date: ______

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No.580, Gan Xi Road, Changning District Shanghai, China 200335

Tel:(8621) 6238-3511Fax: (8621) 5218-0390Website: Email: