Enrollment form Registration Form "*" indicates required fields Student’s InformationFirst and Last Name:* First First and Last Name:* First Parent(s)/Guardian(s) Full Name(s):* 1. 2. (if applicable) Birth Date:* Mon Day Year Gender* Male Female Student's Grade in the Farsi School:* K 1A 1B 2A 2B Youth Camp (12 year & up) Adult Do you have another student?* Yes No First and Last Name:* First First and Last Name:* First Parent(s)/Guardian(s) Full Name(s):* 1. 2. (if applicable) Birth Date:* Mon Day Year Gender* Male Female Student's Grade in the Farsi School:* K 1A 1B 2A 2B Youth Camp (12 year & up) Adult Another student Another studentFirst and Last Name:* First First and Last Name:* First Birth Date:* Mon Day Year Gender* Male Female Student's Grade in the Farsi School:* K 1A 1B 2A 2B Youth Camp (12 year & up) Adult AddressAddress* Street Address City ZIP / Postal Code Home Phone:Cell Phone:*Contact InformationFIRST PARENT/GUARDIAN* Fullname Cell Phone:*Home Phone:*Relationship to student* First Email Address* Second Email Address (If Any)* Primary Language* First SECOND PARENT/GUARDIANFull nameRelationship to studentCell phoneHome phoneEmail addressPrimary languageEMERGENCY CONTACT (OTHER THAN PARENT)Full nameRelationship to studentCell phoneHome phoneEmail addressPrimary languageEmergency Medical InformationMedical Insurance:Insurance Policy #:Physician's Name:Physician's Office #:Does(do) your child(ren) have any food or medication allergies?* Yes No If you answered Yes, please specify:* I undersigned as parent or legal guardian of the above named student do hereby consent to release Avicenna Academy and all their officers, directors and agents from and against all claims, demands, liabilities, actions or causes of action of any sort, liquidated or unliquidated, past, present or future, which arise out of or relate to the classes being conducted including but not limited to physical activities such as sports, dance and etc. I hereby acknowledge that I am responsible for the tuition due to Avicenna Academy. I authorize Avicenna Academy to use photographs and/or videos of my child’s school sponsored activities and/or performances for the school’s purposes including the Avicenna Academy’s school yearbook, calendar, or other social media related to the school. I certify I have read and understood all the above items, and completed all the required fields * I have read and agree to the terms and conditions above.** I agree with Rules and Regulations of Avicenna Academy*Please Print Name:* First Date* Mon Day Year Signature of Parent/Guardian:*you can renew your signature by clicking on the right corner of the icon
