Plan your Visit
Student’s Full Name *
Student’s Date of Birth *
Child’s Age *
Address *
Mobile Number *
Emergency Contact Number *
Mother’s Full Name*
Father’s Full Name*
Is the child allergic to any foods or medications? *
NoYes
Is your child current on all required immunization? *
YesNo
Can your child’s picture be used for Shri Navagraha Devasthanam’s documentation and promotional purposes? *
I would like to enroll my child in the above mentioned Bala Vikas Program @ Sarvamangala Shri Saneeshwara 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 (required)
Signature *
