ICC New Account Application Form

In order to establish your account for ICC, we need the following personal
information from you. This information will be treated confidentially. 

  *Home Phone Number:         Will be used as your login id
  (Area code with no - or space)
  
  *Contact 1 Name:            Chinese:  (ncn for no Chinese name)
  (Last, First)
  
  *Contact 2 Name:            Chinese:  (ncn for no Chinese name)
  (Last, First)  

  *Street Address:          
  *City:                    
  *State:                   
  *Zip:                      (Enter zip code first to get the state and city autofill)
  
  *Email address:           
  
  *Phone 1:            
  (Area code with no - or space)
  
  *Phone 2:            
  (Area code with no - or space)
  
  Referral Phone Number:  
  
  Please check the courses you or your kids are going to take this semester (2021 Spring):

  * Use the C button to copy the content from the field above 
 

 
SelectedCourse IDStudent NameChinese NameBirth DateGender

 
 Course 1
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  
 Course 2
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  
 Course 3
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  
 Course 4
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  
 Course 5
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  
 Course 6
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  
 Course 7
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  
 Course 8
  (Last, First)(Optional)//(mm/dd/yyyy)
  

  

Have you used this system before? Yes  No 

If you have never used this system before, please select your password:  


  Password:          
  (At least 8 characters)
  
  Retype Password:   
  (At least 8 characters)  

  Before you submit your application, you might want to print your 
  application form for future reference.