Pathshala Registration Form

Submitted by admin on Sun, 08/22/2010 - 6:04pm

Child1

Name: *

Date of Birth: *

Email:

Child2

Name:

Date of Birth:

Email:

Address1: *

Address2:

City:

Zip: *

Father's Name: *

Mother's Name: *

Parent's Email Address: *

Telephone #

Home Phone #:

Cell Phone #: *

Preferred Meeting Time

Day of Week:

Time of Day:

Morning

Afternoon

Evening

Does your child have any allergies?:

Any medical condition we should be aware of?:

Willing to Volunteer:

Yes

I can volunteer/help out by :

Please list goals for your children this semester of Patshala:

By clicking on the Submit button below, you agree to release the Jain Society of Central Florida, its officers, volunteers and agents from any liabilities for any accidents or injuries that your child may incur attending the field trips, and activities at the Jain Center.

Jain Society of Central Florida

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Pathshala Registration Form

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