ENGLISH & COMPUTER CLASS REGISTRATION FORM

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Policy: Parents or Guardian must sign on the form and all the information provided are confidential and secured.

Personal Information

First name

Last name

Date of Birth

Gender

Level of Education

Phone

Email

Address

City

state

zip

Social security

Date of Arrival in USA

Emergency Contact

Name

Phone

Email

Address

City

state

zip

I give you permission

TO attend summer

To travel with staff and volunteer from shalom community impact center To be including in photos, website of shalom taken during the program

Parent or Guardian Signature

Upload a scaned signature here