M.U. Ṣalāh Summer Camp
For Kids & Youth 5+ Qur'ān, Islamic Studies, Indoor & Outdoor Activities
# of students enrolling
*
1
2
3
4
Guardian Information
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Parent/Guardian Name
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First Name
Last Name
Phone Number
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Email
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Confirmation Email
example@example.com
Student Information
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Name
*
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
"...and the male is not like the female" (Āl 'Imran: 36)
Student #2
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Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
"...and the male is not like the female" (Āl 'Imran: 36)
Student #3
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Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
"...and the male is not like the female" (Āl 'Imran: 36)
Student #4
Please fill out the following information.
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
"...and the male is not like the female" (Āl 'Imran: 36)
Media Release Form
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Does the Masjid Uthman staff have permission to take and share photos of your child(ren), and release it on the Masjid Uthman website/media outlets?
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Yes
No
Emergency Release Form
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Does your child(ren) have any allergies?
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No
If you chose "YES" please specify.
*
Do you allow Masjid Uthman to call Emergency Medical Services (EMS) in case of an emergency?
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Yes
No
Emergency Contact Name (Other Than Yourself)
*
First Name
Last Name
Emergency Contact Phone Number ((Other Than Yourself)
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Student Fee
Select if you're signing up 1 student
$
120.00
Quantity
1
2
3
4
5
6
7
8
9
10
2 Students Fee
Select if you're signing up 2 students
$
240.00
Quantity
1
2
3
4
5
6
7
8
9
10
3 Students Fee
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$
360.00
Quantity
1
2
3
4
5
6
7
8
9
10
4 Students Fee
Select if you're signing up 4 students
$
480.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
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Signature
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