Quran Program Waiver

First Name* Last Name* (student name) has my permission to participate in the Quran program hosted by Aisha Fatima Community on Mondays-Thursdays, September 2-December 18, 2025.

Should it be necessary for my child to have medical treatment while participating in this program, I hereby give the program personnel permission to use their judgment in obtaining medical services, and I give permission to the physician selected by the program personnel to render medical treatment deemed necessary and appropriate by the physician. I understand that the program has no insurance covering any medical or hospital costs incurred and therefore, any costs incurred for treatment shall be my sole responsibility.

My child is covered by medical/accident insurance.My child is not covered by medical/accident insurance.

Each person participating in the Aisha Fatima Community program (and for minors, their legal guardian) is deemed to have waived all claims against Aisha Fatima Community and its employees and agents for injury, accident, illness or death occurring during or by reason of participation in this program.

I have read and understand the foregoing statements and agree to assume the responsibility stated and waive all claims. I have also clearly indicated ALL pertinent medical diagnoses, physical/medical limitations and corresponding medications on this waiver.

Parent Printed Name:*

Parent Signature:*

Parent Email: *

example@example.com

Mother's Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Father's Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Other number, if not applicable. Please specify who the number belongs to and what their relation is to the child.

Mother's Phone NumberFather's Phone NumberOther

Date*

Date

Healthcare Provider, Insurance details, and add notes regarding Medical insurance:*

Additional information about child: