2007 – 2008 REGISTRATION FORM

CHINMAYA MISSION CHICAGO

NW INDIANA REGIONAL CENTER

At IACC, 8605 MERRILLVILLE ROAD, MERRILLVILLE - IN 46410

Sundays 4:30pm – 6:30pm from Sept 16th ‘07 – June 8th ‘08

Family Name:______________________________ Home Phone:_______________

Mother’s name:_______________________Father’s name:___________________

Cell phone #(s):_______________________ _________________________________

Mailing address:______________________ ______________________________

City:___________________________State:__________________Zip:_____________

Parents e-mail: (1)____________________________(2)_______________________

Child’s name Birthdate School grade enrolled in

(mm/dd/yy) 2006/2007
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________

Please enroll my son/daughter in Bala Vihar/Yuvakendra program starting on September 17th 2006/June 10th 2007.

Enroll following in the Adult discussion group:

Both parents:_________ Father only:__________Mother only:____________


A donation of $75/per person/ maximum of $150/ per family for the school year 2007/2008 should be enclosed with this completed form.

Please make check payable to Chinmaya Mission NW Indiana.

For office use only

Date:_____________paid by check #________ / Cash:_______Amount:________

For further information contact

Padmini Makam at 322 -7268/ cell 808 -3134

Suchita Shah at 924 -7105 cell 614-1106 padminimakam@comcast.net /suchita1259@gmail.com


Mail the completed form along with your check to

Suchita Shah, 10411 Victoria Ct, Munster, IN 46321

Dhanyavaad