Intensive Qur'an Review Program

Parent/Guardian Details
Parent/Guardian Name *

First Name Last Name
Relationship *
(Father, Mother, Guardian, etc.)
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Student(s) Information *
Emergency Contact Info
Emergency Contact *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Relationship to Student/Family *
Permission to Pick up Child(ren): *

Yes No
Terms of Agreement

Please read thoroughly before signing this form.
- In the event of an emergency, if I cannot be reached, I authorize the calling of a doctor/Certified Emergency Personnel and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that although the Darul-Tarteel Weekend Hifdh will be staffed by mature and responsible adults who will do their best to ensure the well-being of my child/children, I shall not find the Darul-Tarteel Weekend Hifdh, the Abu Huraira Center, or their staff liable for any injury or loss of property.
Photography & Media Release

Please read thoroughly before signing this form.
- I hereby give Abu Huraira Center and its partners and affiliates consent to use and reproduce my child(ren)'s name/image for promotional purposes related to Abu Huraira Center, its member programs, and/or external partners. My child’s first name (unless otherwise authorized)/image may be published or used in newspapers, promotional videos, television commercials, program brochures, posters, on the World Wide Web or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by Abu Huraira Center, its member programs, and/or external partners.
Parent Signature *

Clear
Date Signed *

Month Day Year
Date
Payment Information

(Tuition is $100 per child per month. There will be a one time fee of $20 to cover administrative costs. Only payment option is monthly bank withdrawals on the 23rd of every month. There is a $25 NSF charge. All requests to stop automatic withdrawals must be given ONE (1) month prior. No Electronic Funds Transfer (EFT) cancellations last THREE (3) months of school year.)
Name of Account Owner *
Please enter name as stated on void cheque/direct deposit form
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Bank Name *
Account Number *
Institution Number *
Transit Number *
Withdrawal Date *

Month Day Year
Select a date (before the 10th of the month) you wish for Darul-Tarteel Weekend Hifdh to process your monthly fees from your account. This will be auto-recurring.
Signature *

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Parent/Guardian Details

Terms of Agreement

Photography & Media Release

Payment Information

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