CMA Academy Registration Form

The Community Mosque Academy, Inc

2023-24 Registration Form – Sunday School
Please complete one per family:

Parent Information
Mother/Guardian Name*

First NameLast Name
Mother/Guardian Email
example@example.com
Father/Guardian Name*

First NameLast Name
Father/Guardian Email
example@example.com
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Emergency Contact Name

First NameLast Name
Emergency Contact (School Hrs)*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student 1 information
Student 1 Name*

First NameMiddle NameLast Name
Email
example@example.com
Gender
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Grade
Student Type

Student 2 Information (Skip if not applicable)
Student 2 Name

First NameMiddle NameLast Name
Email
example@example.com
Gender
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Grade
Student Type

Student 3 Information (Skip if not applicable)
Student 3 Name

First NameMiddle NameLast Name
Email
example@example.com
Gender
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Grade
Student Type

Student 4 Information (Skip if not applicable)
Student 4 Name

First NameMiddle NameLast Name
Email
example@example.com
Gender
Phone Number
Please enter a valid phone number.
Grade
Birth Date

MonthDayYear
Student Type

Tuition Fee

Please pay at the CMA office
Tuition Fee (Select one)

$200 - 1 Child$300 - 2 Children$375 - 3 Children$450- 4 Children$525 - 5 Children$620 - 6 Children
Medical Information ( Food Allergies etc)

Medical Information
Physician Name

First NameLast Name
Physician Primary Phone Number
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Preferred Emergency Hospital Name
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.

Signature
Any other Special Notes
Should be Empty: