Masjid Assalam (Canadian United Community of Ugandan Muslims)
Program Name: Children's Islamic Classes
Participant Information
First Name
*
Middle Name
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Health Card Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Does the Participant have any medical illness or allergies?
*
Yes
No
If yes, please indicate
Family and Emergency Contact Information
First Contact
Parent/Legal Guardian
*
First Name
Last Name
Relationship to Participant
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Second Contact
Parent/Legal Guardian Name(First, Last)
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
First Name
*
Last Name
*
Relationship to Participant
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Pick Up and Sign In/Out
Including parents, list caregivers who are authorized to pick up participant. Staff must receive the parent/guardian's written authorization to release a participant under 18 years of age to an authorized caregiver who is 12 years of age or older. Contact information must be completed by the person who has agreed to act as Authorized Caregiver contact.
Authorized Caregiver First contact
First Name
*
Last Name
*
Relationship to Participant
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Caregiver Second contact
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Caregiver Third contact
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Children must be 10 years of age to sign in and out by themselves.
I give permission for the participant to SIGN IN & SIGN OUT at the program location, without a parent/authorized caregiver present.
Yes
No
Consent
I authorize Masjid Assalam, (CUCUM), to photograph, record video or audio, and/or interview the participant. I understand that this material may be used for marketing, promotional, or informational purposes by Masjid Assalam, (CUCUM), across various media platforms.
Yes
No
To be completed by parent or legal guardian if participant is under 18 years of age or incapable of giving consent. I have read this form after it was completed, and the information is accurate. I give consent for the participant to take part in the Children’s Islamic Classes
Yes
No
Parent/Legal Guardian Name (First, Last)
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: