Student Registration Form

Student Registration Form 2023-2024

Credit:

Attendance

In Person Online

Student’s Name:

نام و نام خانوادگی

Please use the Farsi keyboard below to type your name and copy and paste it into the field above.

Farsi Persian Keyboard (صفحه کلید فارسی)

Birth Date:

Gender

Male

Female

Age

Current Grade at your school:

Current Grade Farsi classes (ISSD):

School Name:

School District

Address:

City:

State:

Zip Code:

Contact E-Mail:

Contact Phone:

Mother’s Name:

Mother’s E-Mail:

Father’s Name:

Father’s E-Mail:

Mother’s Work Phone:

Mother’s Cell Phone:

Father’s Work Phone:

Father’s Cell Phone:

Emergency Information

Allergies?

In case of an emergency, please give us the name of two people (besides yourselves, we will always try to reach you first), that we can contact, in order of their priority.

Emergency Contact Name 1:

Emergency Contact Name 2:

Classes

Emergency Contact Phone 1:

Emergency Contact Phone 2:

- In the event of a medical emergency, I (we) consent to the decision made by the supervisors of the program or any and all of its agents relating to the provision of medical assistance.

-I (we) hereby expressly waive the benefits and provision of Section 1542 of the Civil Code of the State of California, which section provides as follows:“A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him, must have materially affected his settlement with debtor.” This release may be placed as a full and complete defense to and may be used as the basis for an injunction against any action, suit, claim or other proceedings of any type which may be prosecuted, initiated or attempted in violation of the terms hereof.I authorize the Iranian School of San Diego to use photographs and/or videos of my child’s school-sponsored activities and/or performances for the school’s purposes including any school & PCC publications and website.

- I agree to terms and conditions.

Note

Name of person completing this form

Relation to Student:

Date: