Registration

For Online Registration , Please kindly fill up all requires field and hit Submit button at the end .

Student Information: *

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Gender

Male
Female

Birthplace: *

Date of Birth *

Student Information: ( Second child )

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Last

Gender (Second Child)

Male
Female

Birthplace: (Second Child)

Date of Birth (Second Child)

Which Location are you applying for ? *

Primary Parent / Guardian Information: *

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Occupation: *

Address Line 1 *

Street Apt No

Address Line 2 *

City , State , Zip

Home/Cell phone *

Email *

2nd Parent / Guardian Information: *

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2nd Parent / Guardian Occupation: *

2nd Parent / Guardian Address *

2nd Parent / Guardian Phone/Cell

2nd Parent / Guardian Email *

Emergency Contact #1 Information : *

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Emergency Contact #1 Phone/Cell *

Emergency Contact #2 Information : *

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Emergency Contact #2 Phone/Cell (copy) *

Insurance Company : *

Insurance Policy Number : *

Child has the following problems/ restrictions/ allergies/ medical conditions:

Permission to allow school authorized personnel to take any necessary action in time of emergency: *

Parent / Guardian Name (print): *

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Nima Farsi Class Field Trip Release: I grant permission for my child/children ,to participate in Nima Farsi Class field trips during 2019-2020 school year. In case of any emergency I grant permission to allow school authorized personnel to take any necessary action in time of emergency. I understand and acknowledge that my child’s participation in such field trips will be deemed a waiver of all claims against Nima Farsi Class and ICCES, their teachers, officers, agents, and for injury, accident, or death occurring during or by reason of such field trips. I agree to hold myself liable for damage, theft, and lost personal property. This authorization is given and shall remain effective until my child is withdrawn from Nima Farsi Class or unless permission is revoked in writing. *

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Nima Farsi Class Field Trip Release:

Nima Farsi Class Release and Authorization to Use Student Image: Nima Farsi Class or ICCES may produce or participate in video, motion picture, audio recording, web page, or still photograph productions, broadcasts, and/or publication, which may involve the use of students’ names, likenesses, or voices. Such productions will be used for advertising, exhibition, promotional, or other purposes. Such productions may be copied, copyrighted, edited, and distributed by Nima Farsi Class or ICCES in the manner described above. I understand that my and/or my child’s name, likeness, or voice may be used in the manner describe above, and grant Nima Farsi class and ICCES the right to use and reuse, in any manner at all, the video, motion picture, audio recording, web page, or still photograph productions, broadcasts, and/or publications as described above. I hereby forever release and discharge Nima Farsi Class & ICCES from any and all claims, actions and demands arising out of or in connection with the use of above said productions without limitation, any and all claims for invasions of privacy and libel. This release shall inure to the benefits of the assigns, licenses and legal representatives for Nima Farsi Class and ICEEC. I have read and fully understand the contents hereof. *

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Nima Farsi Class Release and Authorization to Use Student Image

Release of Directory Information: Directory information is information about a student and family that would not generally be considered harmful or an invasion of privacy if disclosed. Directory information may include: a student’s and parent’s name, student’s or parent’s telephone number, student’s or parent’s email address, Student’s photograph, Student’s grade level, and honors and awards received. The primary purpose of directory information is to allow the Nima Farsi class to share these information with PTA members, board of directors or other student’s parents who are currently attending to Nima Farsi class. Nima Farsi Class may share photograph on its website but will NOT share any other information include student’s or parent’s name, telephone number, email address or any other information on its website or to outside organizations or 3rd parties without a parent’s or guardian’s prior written authorization. This release is optional. If you do not want the Nima Farsi Class to release directory information from your child’s or your information with other families or PTA members you must notify the Nima Farsi Class management before first day of school year and all student’s and Parent’s Directory information will only remain accessible to Nima Farsi Class management and Board of Directors. I consent to Nima Farsi class use of my student’s photographs, video image and audio recording on its website and I agree to allow my directory information and my student’s information to be released to other Nima Farsi Class’s parents and PTA members. *

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Release of Directory Information:

By Clicking on this box and submitting this form, you confirm that you have read and agree to the official rules and terms and all the information are accurate and you are acting as yourself .

I Agree

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