REGISTRATION FORM
Field marked with * are mandatory.
Personal Details
Name :
Home Phone :		Cell Phone:
Email Address :
Address :
Would like to register in the following class/classes:
Date of Birth:	- - January February March April May June July August September October November December -	Grade:
Parent’s name :	Mother	Father
Mother's Cell Phone :		Father's Cell Phone:
Mother's Email Address :		Father's Email Address :
Emergency contact & number:
Signature (by parent or guardian if minor): I hereby indemnify Young Indian Culture Group, Inc. from any and all liabilities that may occur due to the conduct of the classes, activities and performances at Herricks Middle School and any other location. I give permission to YICG, Inc. to photograph and to publish in print, electronic, or video format the likeness or image and the student work of my child.
*****Sign :		Date :
'All information is private and will not be provided to any person or agency'