Clone of Viet My Student Registration Form 2025-2026

Viet My Cultural Center

vietmy.culturalcenter@gmail.com

www.vietmyculturacenter.org

(240)243-8566
Student Registration Form
- Full Name
  
  First NameMiddle NameLast Name
- Full Vietnamese Name (if any) - Please put all accent marks
- Grade
  for Incoming A.Y. '12-'13
- Birthdate
  
  MonthDayYear
  Date
- Current English School
- Past Vietnamese School + Grade
- Allergies/Medical Conditions
- Sibling 1
- Name
  
  First NameMiddle NameLast Name
- Full Vietnamese Name (if any) - Please put all accent marks
- Birthday
  
  MonthDayYear
  Date
- Grade
- Current English School
- Past Vietnamese School + Grade
- Allergies/Medical Conditions
- Sibling 2
- Name
  
  First NameMiddle NameLast Name
- Full Vietnamese Name (if any) - Please put all accent marks
- Birthday
  
  MonthDayYear
  Date
- Grade
- Current English School
- Past Vietnamese School + Grade
- Allergies/Medical Conditions
- Sibling 3
- Name
  
  First NameMiddle NameLast Name
- Full Vietnamese Name (if any) - Please put all accent marks
- 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
- Skills/Talents
- Sports
- Interests
- Suggestions / Comments
- I give consent for my child's photo to be taken and posted
- Please verify that you are human
- Parent Signature
  
  First NameLast Name
- Should be Empty:

Student Registration Form

Sibling 1

Sibling 2

Sibling 3

Medical Information

Parent/Guardian Information