Student's Name *

First Name

Last Name

Parent's Name (If the student is a minor)

First Name

Last Name

Enrollment Status *

Please check all that apply.

Returning Student

New Student

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Contact

Please check all that apply.

Phone

Email

SMS

Term *

Please check all that apply.

Fall 2024

Winter 2024/25

Spring 2025

Choose your class(es) *

Please check all that apply.

Khmer Language Class for Children

Khmer Language Class for Adults-Beginner Level 1

Khmer Language Class for Adults-Beginner Level 2

Khmer Language Class for Adults-Intermediate

Pinpeat Music Class

Khmer Traditional Music

Khmer Dance Class for Children and Teens

Method of Payment *

Please choose your payment method. We are currently not accepting cash payments. If you are paying by check, please make is payable to National Cambodian Heritage Museum & Killing Fields Memorial. Our mailing address is 2831 W Lawrence Ave | Chicago, IL 60625.

Mail in check

Credit Card

Date of Registration *

MM

DD

YYYY