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My child speaks fluent SamoanMy child speaks limited SamoanMy child cannot speak SamoanMy child understands SamoanMy child understands limited SamoanMy child does not understand/speaks Samoan

Please enter names and dates of birth of additional children:

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Speaks SamoanSpeaks limited SamoanDoes not speak Samoan

Speaks SamoanSpeaks limited SamoanDoes not speak SamoanN/A

This release form grants permission to collect ongoing academic and behavioral information on students involved in the program. This information will remain strictly confidential and used solely for assessing the success of the program.YesNo

I hereby give permission for my child's work, which may or may not be accompanied by the child's name, and/or photograph to be electronically displayed (in web pages, print, or video productions) and hereby release the Le Fetuao Samoan Language Center from any liability resulting from or connected with the publication of such work.YesNo

I give consent for the Le Fetuao Samoan Language Center to take or use photos/videos of my child for commercial or non-commercial educational purposes. I understand my child's ongoing academic and behavioral information will be collected in a strictly confidential manner. LFSLC may use this data for promotional and educational purposes of the program.YesNo

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