Masjid Salahadeen- Sunday School Registration Form
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Preferred Medical Facility
Name of Physician/Pediatrician
First Name
Last Name
Phone Number
Please enter a valid phone number.
Any Allergies or Medical Conditions?
Yes
No
Please give details
Do you want to add something about your child?
Please upload a profile picture of the child
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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.
Masjid Salahaddeen will not be held responsible for any bodily injury that occur on its premises.
Date
-
Month
-
Day
Year
Date
Signature
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