HCCS Wushu After-School Program (Fall 2026) – Student Registration Form

***ONLY ONE STUDENT PER FORM*** To be filled out by parent/guardian if under 18 years of age. Taught by Summit Wushu Academy for students ages 5 – 12 years.

Student Information

First name

Last name

Date of Birth

Age

Grade

Gender

Other

Address

Zip Code

Phone Number

Email address

Emergency Contact

Contact Name

Relationship to student

Phone #

Additional Information

Please list any medical conditions and/or anything we should be aware of

How did you hear about us?

Additional notes (if applicable)

Payment

The cost of the course is $275. There are TWO options for tuition payments. Please follow the instructions to ensure we receive your payment correctly. A) Online payment through ZELLE. Please send it to summitwushu@gmail.com and write the student's full name and "HCCS wushu" in the memo section. B) Bring a check on the first day of class. Make checks to “Summit Wushu Academy”

I agree to the these terms and will provide the payment as per the above instructions.

Waiver and Release

I do hereby agree to allow my child(ren) to participate in Hope Chinese Charter School’s after-school Wushu program taught by Summit Wushu Academy (the Instructor). I recognize the risks of injury that are common to any performing arts program that my child participates in and I do hereby waive and release Hope Chinese Charter School and the Instructor from and against any and all claims, actions, causes of action, damages, costs, liabilities, expense of judgments, including attorney’s fees and court costs, that arise out of my child’s participation in this program. I understand that photos/videos may be taken of my child(ren) during class for Hope Chinese Charter School’s promotional purposes. I hereby execute this Waiver and Release form permitting my minor child to participate in the Wushu after-school program. There are no refunds. Any student who miss class from the after-school program may come to either the Clackamas or Beaverton location class times per Sifu Peter Dang’s discretion.

I have read the above and agree to the conditions set forth by Hope Chinese Charter School & Summit Wushu Academy,

Today's date

Full name of the undersigned

Signature (parent/guardian required if under 18 yrs)

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