2769 Duluth Highway Duluth, GA 30096

www. radhamadhavsociety.org; http://yugalkunj.org , Devyani Telang (404)510-4403

Harmonium and Vocal Class Registration Form

(One application per family)
*Registering Child must be at least 5 yrs. old

Please check one:

Beginner Child: Saturday; 11:15am to 12:00pm $120
Beginner Adult: Saturday; 12:00pm to 12:45pm $120

Youth/Child 1
First Name: __________________________ _ Last Name: ___________________________
Age: ______ Date of Birth: ___________ Grade: ____ Gender: Male/Female
MM/DD/YY
Youth/Child 2
First Name: ___________________________ Last Name: ___________________________
Age: ______ Date of Birth: ___________ Grade: ____ Gender: Male/Female
MM/DD/YY

Youth/Child 3
First Name: ___________________________ Last Name: ____________________________
Age: ______ Date of Birth: ___________ Grade: ____ Gender: Male / Female
MM/DD/YY

Address
Street Address: ________________________________________________________
City: _________________________________ State: _______ Zip Code:_________
Parent or Primary Contact Information
1. Parent/Primary Contact: ___________________________________Relationship: ______________
Tel (Home) :______________ Cell #:__________________
Email Address: ____________________________________
2. Parent/Contact: ______________________________________ Relationship: ______________
Tel (Home): ______________ Cell #:__________________
Email Address: ____________________________________
Emergency Contact
Name: _______________________________________________ Tel #:______________________
Known Allergies or Medical Conditions:

________________________________________________________________________________
________________________________________________________________________________

I authorize (Name): ______________________ to pick up my child/children from Yugal Kunj.

I have received and read the Rules and Regulations. By signing , I indicate my acceptance.

Signature:_________________________________ Date:_____________

Are you a life member of RMS? ________________________________________________________

How did you hear about us? ___________________________________________________________

Any other comments: _________________________________________________________________

Parent's Signature: ______________________________ Date:_______________

Yugal Kung Official Use Only

Date Received:____________ Coordinator Signature:___________________________

Comments:____________________________________________________________________

Mode of Payment: Cash_____ Check___________ Credit Card________ PayPal________

Please make checks payable to Radha Madhav Society (Write in For : Child's / Children Name)