MAS SUMMER PROGRAM 2026
Al Huda Mosque
Father Name
*
First Name
Last Name
Father Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mother Name
*
First Name
Last Name
Mother Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Information:
1st Child Name
*
First Name
Last Name
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Age
2nd Child Name ( if applicable)
First Name
Last Name
Gender
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
Age
3rd Child Name ( if applicable)
First Name
Last Name
Gender
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
Age
4th Child Name ( if applicable)
First Name
Last Name
Gender
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
Age
5 th Child Name ( if applicable)
First Name
Last Name
Gender
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
Age
Does you child have known Allergies/ Medical Problems we need to be aware of?
*
I hereby agree to accept all financial responsibility and give consent for any medical, surgical or dental attention to maintain the health of the above‐named children (Kindly sign Below)
*
I agree to absolve MAS and their staff from all liability that may arise as a result of participation in the above activities. I am also to report any medical problem that is serious or life threatening to the child. I agree to all policies and procedures of MAS. (kindly sign below)
*
Questions or Concerns
What are your questions or Concerns?
How would you like to pay?
*
Cash
Card
Check
Sign- Full name
*
Submit
Should be Empty: