Name of the Child
Child's date of birth
Primary Registrant name
Primary Registrant email address
Primary Registrant home Phone number
Address
City
State
Zip Code
On behalf of my child, I have read and agree to the terms and conditions below	YES, I agree
Image Verification Please enter the text from the image: [ Refresh Image ] [ What's This? ]

Terms and Conditions: Membership commences on the first day of the next month date (after this form is signed) and is valid for exactly one year thereafter.

I, have read the membership policy and hereby make an application for membership at the India Community Center. In case of emergency or if I/we become injured while attending or participation in any India Community Center (ICC) event or program, I give permission to any licensed physician, surgeon, clinic or hospital to secure proper treatment for the individuals named in this application, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. I hereby release, forever discharge and agree to hold harmless Indian Community Center, its associates and directors hereof from any and all liability, claims or demands for personal injury, sickness or death , as well as property damages and expenses of any nature whatsoever which may be incurred while participating in any activity at the center. I/My family will abide by the ICC’s code of conduct. I agree that there will not be any refund incase I cancel my