Samskritam Classes Registration for 2016-17
Enter Primary Student Details
Primary Student Name
*
This name is for Hector and Co to refer to
Telephone
*
-
Area Code
Phone Number
Mobile
*
-
Area Code
Phone Number
E-mail
*
Desired Level for Primary
*
Level 1 - All New Students
Level 2 (1:45 - 3:00 PM)
Level 3 (3:00 - 4:15 PM)
Desired Time Slot for Primary
*
1:45 - 3:00 PM
3:00 = 4:15 PM
Additional Members ?
SPOUSE - I want to add my spouse as a student
CHILD(REN) - I want like to my child(ren) as students
Add Spouse
Spouse Name
*
This name is for Hector and Co to refer to
Desired Level for Spouse
*
Level 1 - All New Students
Level 2 (1:45 - 3:00 PM)
Level 3 (3:00 - 4:15 PM)
Desired Time Slot for Spouse
*
1:45 - 3:00 PM
3:00 = 4:15 PM
Add Child(ren)
# of Children
Please Select
1
2
3
Child Name 1
*
Child Name 2
*
Child Name 3
*
Is Child 1 a New Student?
Yes
Is Child 2 a New Student?
Yes
Is Child 3 a New Student?
Yes
Child 1 Grade Level
*
K to 1st Grade
2nd Grade
3rd to 5th Grade
6th Grade & Above
Child 2 Grade Level
*
K to 1st Grade
2nd Grade
3rd to 5th Grade
6th Grade & Above
Child 3 Grade Level
*
K to 1st Grade
2nd Grade
3rd to 5th Grade
6th Grade & Above
Back
Next
Agreement
*
I, the undersigned, hold Samskrita Bharati USA, and BalGokul run by VHPA Inc. harmless for any and all liabilities arising out of me and/or/my children’s participation in the Samskritam class. In the event of medical emergency, any medical help available to the organization may be used. I will be responsible for all medical and related expenses. I hereby, release Samskrita Bharati USA, VHPA Inc. and Fairfax County Public Schools from any and all claims. I further agree to abide by the terms and conditions of the program, rules and regulations as decided by BalGolkul of VHPA Inc. and Samskrita Bharati, USA from time to time. Please check this box. Registration form is incomplete without checking this box. (contact dc@samskritabharatiusa.org for clarifications)
Payment Method
*
Will Bring Check to Balakendram on or before June 12th
Will Mail Check to Address shown in Website
TotalSpouse
child1
child2
child3
Total
Submit
Should be Empty: