2020 Spring Basketball (Student)
* Required
Student Application Form
Email*
Location & Fee*
Student's Legal Name*
Student Nickname
Date of Birth*
Gender*
Grade*
Diagnosis*
Allergy*
Any other medical issues?*
Any Behavioral Issues (please be as specific as you can)?*
Receive ABA therapy service?*
Student's T-shirt size (adult size)
Parent / Guardian
Legal Name *
Relationship*
 
Parent/Guardian's Phone Number*
Address *
Parent/Guardian's Email Address*
billing Information
First Name *
Last Name *
Address *
city *
States *
Zipcode *
credit card Information
Credit Card Type *
Credit Card Number *
Name on Credit Card *
Exp month *
Exp Year *
Security Code *
Authorization
Korean American Special Education Center is not responsible for any injury or accidents during the services provided by KASEC. *
Yes
No
I verify this information is true to the best of my knowledge. Applications with falsified information will not be considered.*
Yes
No
I fully authorize and grant the Korean American Special Education Center and its authorized representatives has my permission to use my or my child’s photograph publically to promote the center. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.*
Yes
No
The Registration fee is required for all qualified applications. This fee is not refundable and cannot be credited against any other charges. *
Yes
No
I have read all of KASEC Student Policies & Behavior Contract and understood them completely.*
Yes
No
Please enter the full legal name and date of birth of the person authorizing the application (신청하시는 분의 이름과 생년월일을 사인으로 대신합니다). *
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