Register for Program
*
September Monday Classes
September Saturday Classes
Islamic Youth Camp
Maktab Sunday Classes
Child’s Name (1)
*
Date of Birth (1)
*
Child’s Name (2)
Date of Birth (2)
Child’s Name (3)
Date of Birth (3)
Parent's Name
*
Cell Phone
*
Email
Child 1's Current School
*
Child 2's Current School
Child 3's Current School
Mosque affiliated with & Imam’s name (where applicable)
Copy of Birth Paper
*
Yes
No
Child 1's Medical Conditions
*
Child 1's Allergies
*
Child 1's Learning Disabilities
*
Child 1's Medication to have administered
*
Child 1's Last tetanus shot date
*
Child 2's Medical Conditions
Child 2's Allergies
Child 2's Learning Disabilities
Child 2's Medication to have administered
Child 2's Last tetanus shot date
Child 3's Medical Conditions
Child 3's Allergies
Child 3's Learning Disabilities
Child 3's Medication to have administered
Child 3's Last tetanus shot date
Copy of current Immunization Card
*
Yes
No
By checking this box, in case of accident or illness, I hereby consent to the administration of aid and/or medication. I also consent for treatment by a physician or emergency department. I understand that I will be responsible for the cost of such treatment where applicable, for which I will be notified in advance through reasonable effort by personnel of the Institute.
*
Yes
No
Primary Contact Name
*
Contact Number
*
Alternate Contact Name
*
Contact Number
*
Email
I, the parent/legal guardian of the participant(s) listed on this form, certify that he/she/each of them has my full approval to participate in this event and any associated off-site events. The participant identified on this form and I, the parent/legal guardian, understand that all participants are expected to abide by the event rules and be directly responsible to the event director/staff. I, the parent/legal guardian, will assume full responsibility for returning the participant to his/her home.
I have read and agree to the information given in its entirety on this form.
*
Yes
No
Date
*