Student's First Name *

First Name

Last Name

Student's Last Name *

First Name

Last Name

Student's Date of Birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Full Name

First Name

Last Name

Father's Full Name

First Name

Last Name

Parent's Cell Number *

The cell number will be added to the parent's Bala Vikas 2020-21 WhatsApp group

(###)

###

####

Is your child current on all required immunization? *

Yes

No

Is the child allergic to any foods or medications? *

Yes

No

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

Yes

No

Yes, 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