Student Information:

Student Name	Address	Age:	What is this child’s interests (e.g., reading, music, specific sports, dancing, singing, etc.)	Slovak Language Fluency (see below)	Group Level (I or II)

Slovak Language Fluency:

1 – child does not speak Slovak 2 – child can speak or understand some Slovak

3 – child can speak Slovak fluently & Slovak is spoken in the home

(Please print)

Parent or Guardian’s Name:

______________________________________________________________________________

Address: ___________________________________________________________________________

______________________________________________________________________________

Phone number (including area code): ______________________________________________________

Email Address: ______________________________________________________________________

Emergency Contact Phone Number: _______________________________________________________

Please send completed application and payment (check made payable to Cleveland Slovak School) to

Mary Ann Dzurec

514 Danbury Lane

Avon Lake, OH 44012

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