Student's Full Name *

First Name

Last Name

Student's Date of Birth *

MM

DD

YYYY

Mother's Full Name

First Name

Last Name

Father's Full Name

First Name

Last Name

Emergency Contact Number *

(###)

###

####

Is the child allergic to any foods or medications? *

No

Yes

Is your child current on all required immunization? *

Yes

No

Can your child’s picture be used for Shri Navagraha Devasthanam’s documentation and promotional purposes? *

Yes

No

I would like to enroll my child in the above mentioned Bala Vikas Program @ Sarvamangala Shri Saneeswara Temple – NY and, I understand that it is my responsibility to pick up my child on time and I also understand that any injury caused to my child while participating in Bala Vikas Program shall not be deemed to be the fault of the Temple or its Teachers and I hereby release the Temple and the teachers from any liability *

Agree

Disagree