Saturday Maktab Registration Form

Daar Ibn Umar: Saturday Maktab

Application Form
Times:

9 AM to 12 PM (Midday)

Seperate Boys and Girls Classes

Address

Level Two

116 Queen St

Campbelltown
Student Information:
Please verify that you are human*
Student's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemale
Current School Grade*
E-mail
Language Spoken at Home
Any Medical Conditions We Should Be Aware Of:
(Allergies/Illness/Medication/Etc.)
Secondary Phone
Parent/Guardian Information:
Please Specify Your Relationship to the Applicant*
Father/Guardian 1*

First NameLast Name
Mother/Guardian 2*

First NameLast Name
Primary Contact No*
Secondary Contact No:
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

SuburbState / Province

Post Code
E-mail
example@example.com
Emergency Contact Information:

(Other than above individuals)
Emergency Contact *
Emergency Phone*
Relationship to student*
Extra Information
*Registration Fees (Non-refundable): Cover enrolment and initial books needed.

* Tuition fees (Non-refundable): $300 per term (10 weeks per term). Fees must be paid in full at the beginning of each Term.

*Note : Completion of this form does not guarantee a spot in the class. We will contact you to confirm enrolment.
Fees to be paid*
Agreement and Waiver and Release

I hereby declare that I am the Legal Guardian of the above child/applicant. I hereby additionally consent to my child or ward, upon his/her admission to Minto Community Study Centre Inc./Daar Ibn Umar, for participation in all Minto Community Study Centre/Daar Ibn Umar activities. And hereby execute this AGREEMENT, WAIVER AND RELEASE on the Applicant's behalf and discharge any and all claims for damages for personal injury, death, or property damage, mental or emotional harm of any kind which he/she/they may have or may hereafter accrue to the Applicant as a result of participation in said activities, except as non-waivable by law. This release is intended to and shall discharge in advance Minto Community Study Centre Inc./Daar Ibn Umar (its officers, employees, volunteers and agents) free and harmless for any loss, liability, cost or expense incurred as a result of his/her death, injury or property damage that the Applicant may sustain while on any premises being used by Minto Community Study Centre Inc./Daar Ibn Umar while participating in programs and activities.

I HAVE CAREFULLY READ THIS AGREEMENT AND WAIVER, AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A LEGALLY BINDING AGREEMENT AND A RELEASE OF LIABILITY, A LEGALLY BINDING CONTRACT BETWEEN MINTO COMMUNITY STUDY CENTRE INC./DAAR IBN UMAR AND ME AND THE APPLICANT. I AGREE TO IT OF MY FREE WILL.
ANY UNENFORCEABLE PROVISION IN THIS AGREEMENT SHALL BE SEVERABLE AND SHALL NOT AFFECT THE ENFORCEABILITY OF ALL OF THE AGREEMENT’S OTHER PROVISIONS.
I Agree to all the above conditions.*

I Agree
Should be Empty:

Daar Ibn Umar: Saturday Maktab

Parent/Guardian Information:

Emergency Contact Information: