CMLA | Chinmaya Mission of Los Angeles

Member/BV Child Registration

Center Information

Center:

Center Address:

Member 1

Name*

Date Of Birth*

Member type within Family*

Primary Secondary

Username (Email) *

Password *

Repeat Password *

Address *

Apt/Suite #

Street address				City
State		Zip code		Country

Home Phone *

Cell Phone *

Office Phone

Profession*

Primary Language Spoken at Home*

Member 2

Name*

Date Of Birth*

Member type within Family*

Primary Secondary

Username (Email) *

Password *

Repeat Password *

Apt/Suite #

Address *

Street address				City
State		Zip code		Country

Home Phone *

Cell Phone *

Office Phone

Profession*

Primary Language Spoken at Home*

Do you have Trust/Company?

Yes No