Student Registration Form

Viet My Cultural Center

vietmy.culturalcenter@gmail.com

www.vietmyculturacenter.org

(240)243-8566
Student Registration Form
- Full Name*
  
  First NameMiddle NameLast Name
- Vietnamese Name*
- Grade*
  for Incoming A.Y. '12-'13
- Birthdate*
  
  MonthDayYear
  Date
- Current English School*
- Past Vietnamese School + Grade*
- Email*
- Phone Number*
  Format: (000) 000-0000.
- Allergies/Medical Conditions*
- Sibling 1
- Name
  
  First NameLast Name
- Vietnamese Name (If any)
- Birthday
  
  MonthDayYear
  Date
- Grade
- Current English School
- Past Vietnamese School + Grade
- Allergies/Medical Conditions
- Sibling 2
- Name
  
  First NameLast Name
- Vietnamese Name (If any)
- Birthday
  
  MonthDayYear
  Date
- Grade
- Current English School
- Past Vietnamese School + Grade
- Allergies/Medical Conditions
- Present Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Medical Information
- Name of Physician*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian Information
- Name of Parent/Guardian*
  
  First NameLast Name
- Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Emergency Contact*
  
  First NameLast Name
- Relationship
  ex. Father, Mother, etc.
- Phone Number Of Person To Contact In Case Of Emergency*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Of Person To Contact In Case Of Emergency
  example@example.com
- ActingArts/CraftsCalculatingDancingDebatingDrawingEatingFashionPhotographyPlaying drumsPlaying guitarPlaying pianoProgrammingSingingWritingOthers (specify below)
- BadmintonBasketballBowlingChessFrisbeeScrabbleSoccerSoftballSwimmingTable TennisTrack and FieldTennisVolleyballOthers (specify below)
- Interests
- Suggestions / Comments
- YesNo
- Please verify that you are human*
- Parent Signature*
  
  First NameLast Name
- Should be Empty:

Student Registration Form

Sibling 1

Sibling 2

Medical Information

Parent/Guardian Information