Chinmaya Mission - Springfield Virginia Registration

1. Are you currently a Chinmaya Mission member?

    If Yes, please indicate the center you attended in 2006-07:

2. Please provide your contact information:

    Primary Email Address:

    Home Address:

    City:                                   State:     Zip Code:

    Home Telephone #:          (e.g.7031234567, Enter numbers without spaces or dashes)

3. Please provide personal information:

First Name Last Name M/F Cell# (optional) Secondary Email Address

Adult1

Adult2

First Name Last Name M/F Age (yrs as on 9/30/07) Grade(as on 9/30/07) Optional Class

Child1

Child2

Child3

Child4

4. Volunteering: Mission programs and events are made possible through parent volunteers. Would you like to receive emails about volunteer opportunities?

Please specify if you are interested in any particular area (e.g. teaching-BV/Language/Music, Facilities, Administration, Cultural, Library, etc.):

Profession(s) (Optional):

5. Please note the Annual Pledge levels:

  a. Sponsor-level: $101 per month (minimum 12 months). This includes Balavihar, Language classes, and 1-yr subscription to the        BalaVihar magazine. You would still need to register for all classes you wish to attend, and keep regular attendance throughout the        year.
  b. $360 Basic Adult Annual pledge per family. Plus $120 (1 child)/$240 (2 or more children) per year for Balavihar.
  c. For Language classes, $100 per person per year. For additional members of the family, $50 per person per class.

I have carefully read the Instructions, and agree to abide by them in entirety.

Note: On Submitting this form, you will be given an Application Number, and a link to a one-page Pledge form. Please print and complete it. Mail the completed form along with check/void check to the following address:

Chinmaya Sevak, 3786 Avenel Ct, Fairfax VA 22033

This information will also be sent to your primary email.

PS: For help or questions on this form, please contact Nagesh Gadamsetty.

	First Name	Last Name	M/F	Cell# (optional)	Secondary Email Address
Adult1
Adult2