H� V� T�n (First & Last Name): ______________________________________________
Address: ______________________________ Tele. (___ )__________________

Mu�n ghi danh tham d� l�p Vi�t Ng� mi�n ph� cho: ______ T�i ho�c _____con t�i
(��nh d�u v�o � th�ch h�p)

Would like to enroll to the Vietnamese class for: _____myself or _____ my child
(Mark in the appropriate box)

T�n l�: ________________________ Sanh n�m:______________________________________
Name of participant:______________________ DOB:___________________

S� �i�n tho�i li�n l�c trong trܩng h�p kh�n c�p: _________________
Emergency (person/phone) contacts:______________________