Saturday Maktab Registration Form
Al-Minhal Academy of Washington Township. Please fill out this form to the best of your ability. If you are enrolling more than one child, kindly fill out a separate form.
Student Name
*
First Name
Last Name
Age
*
DOB
*
-
Month
-
Day
Year
Gender
*
Please Select
Male
Female
N/A
Public School Grade
*
Parent/Guardian Information
Parent/Guardian 1:
*
Relationship to Student:
*
Parent/Guardian 2:
Relationship to Student:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address 1
*
example@example.com
Email Address 2
example@example.com
Medical Information
Any Medical Problems or Needs
Allergies
Emergency Contact Number
Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
My Products
*
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Registration Fee
One Time Registration Fee
$50.00
$
50.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Register Class
Should be Empty: