Gokuldham Vidhyalaya

8/10/2014 11:55 AM

Gokuldham Vidhyalaya

Pushtimargiya Vaishnav Samaj of South-East USA, Inc., “Gokul-Dham”

Announces commencement of 4th year of

Gokuldham Vidyalaya

 Group Age  4-5 Group Age 6-8

                   Group Age 8-10          Group Age 10 and above

Fall Semester starts August 10, 2014

Every Sunday from 12-1pm


Student Name: ______________________________________    

Student Birth Date:___________________________________

Address: ___________________________________________


Parent’s Name_______________________________________

Phone Number: _____________________________

Email: ______________________________________

Any allergies            _________________________________

My child would like to participate in Yoga for additional 20 minutes ______Yes _____ No



Registration for the program is $100 per student per year. Please provide your name to


Tejas Patwa (404) 435-9548


For any information or to add to Email contact list:






Medical release & Media release Form

By my signature below, I hereby give permission for my child(ren)  (names)____________________________________________________________________ to participate in the “Gokuldham Vidhyalaya”. In permitting the above named child to participate in the program, the undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury, bodily injury, property damage or wrongful death occurring to him/herself arising in any way whatsoever or however the same may occur and for whatever period said activities may continue. In the event of illness or injury, I do hereby consent to whatever medical and/or dental treatment are considered necessary in the best judgment of the employees, representatives, volunteers and /or designated agents of “Gokuldham Vidhyalaya” to act for me. I also understand that “Gokuldham Vidhyalaya” does not provide health and medical insurance for participants.

Insurance Information:

Name of Company ___________________________________________

Policy #________________________ Group # ___________________________

Additional Information (please print)

Printed Name of Parent/Guardian ____________________________________________

Address ________________________________________________________________

Home Phone ____________________________ Cell Phone _______________________

In case of emergency, notify ________________________________________________

Relationship of above to minor ______________________________________________

Allergies/Allergic reaction of my child ________________________________________

Medicine being taken by my child ____________________________________________

Other information regarding my child’s health that a doctor should know _____________

Photograph/Media Release: “Gokuldham Vidhyalaya” has my permission to take photographs to be used for publicity purposes. I realize that no commercial use will be made of the photographs or information.

        Agree                       Disagree                    Parent/Guardian signature         ___________________________

A responsible adult must accompany your child to the class site and must pick up your child at the site immediately following the completion of the class.                                                                                                                 

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