MALV Maktab Registration Form

Parents Information

Father's Name *

First Name Last Name

Father's Phone *

Father's Email *

Mother's Name *

First Name Last Name

Mother's Phone *

Mother's Email *

Address Information

Street Address *

Apartment #

City *

Zipcode *

State *

Students Information

How many Students are you registering?

Please select students count to add more students.

Child 1 - Name *

Age *

Grade Level *

Child 2 - Name *

Age *

Grade Level *

Child 3 - Name *

Age *

Grade Level *

Child 4 - Name *

Age *

Grade Level *

Medical Information

Does the student have any of the following? (Check all applicable)

Asthma Heart Disease Epilespsy Allergy Other

Does the student have any sight, hearing or impairment that would require attenion?

Emergency Contact (Name) *

Emergency Conatct Phone *

Monthly Tuition per child

If you're unable to pay the full amount, enter an amount that you can afford

Total Tuition per month

Total Tuition per month *

My Products

TOTAL MONTHLY RECURRING PAYMENT

USD for each month

Recurring payments

Terms and Conditions

• Class schedule is Monday to Friday, 5:00 pm to 7:30 pm
• Monthly tuition fee is $75.00 (Seventy five USD) per child.
• All tuition fees due must be paid before the student can attend class. (Book fee of $25 plus first month’s tuition of $75.00)
• All school rules in written or other form must be always adhered to.

I hereby additionally consent that my child/children, upon admission to Muslim Association of Lehigh Valley (MALV), for participation in all MALV’s Maktab 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 may have or may hereafter accrue to the Applicant as result of participation in said activities, except as non-waivable by law. This release is intended to and shall discharge in advance MALV, and (its officers, employees, volunteers, and agents) from all liability arising out of or connected in any way with the Applicant’s participation in said activities. It is further agreed that this waiver and release is to be binding on the Applicant, his parents/guardians, and assignees. I agree to indemnify and to hold MALV, and (its officers, employees, volunteers, and agents) free and harmless for any loss, liability, cost, or expense occurred as result of his/her death, injury, or property damage that the Applicant may sustain while on the premises of MALV, and 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 MALV, AND ME AND THE APPLICANT. I SIGN 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.

By clicking "Submit" I agree to the above terms and conditions.

Parents Information

Address Information

Students Information

Medical Information

Tuition & Payment

Terms and Conditions