ICMC Karate Program Registration Form
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many children are you registering
Please Select
1
2
3
4
Child 1 Name
First Name
Last Name
Child 1 Date of Birth
-
Month
-
Day
Year
Date
Child 1 Sex
Please Select
Male
Female
Child 2 Name
First Name
Last Name
Child 2 Date of Birth
-
Month
-
Day
Year
Date
Child 2 Sex
Please Select
Male
Female
Child 3 Name
First Name
Last Name
Child 3 Date of Birth
-
Month
-
Day
Year
Date
Child 3 Sex
Please Select
Male
Female
Child 4 Name
First Name
Last Name
Child 4 Date of Birth
-
Month
-
Day
Year
Date
Child 4 Sex
Please Select
Male
Female
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Any Allergies or Medical Conditions?
Yes
No
Please give details
Do you want to add something about your child?
I, undersigned, agree with the following statements:
I am the parent/guardian of the child indicated above.
If emergency medical care is needed and I am unavailable, I authorize the supervising teacher to seek medical treatment for my child.
I am giving my permission to take my child's pictures for classroom projects and post them on the masjid website.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: