Palos Islamic Center UNITE Registration
Child Name
*
First Name
Last Name
Child Grade in School
*
Please Select
6th Grade
7th Grade
8th Grade
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Ticket Type
*
I agree to instruct my child to adhere by the policies and rules set forth by the supervisor(s). I further agree that no supervisor shall be held responsible or liable for injuries or other mishaps caused by my child’s disobedience of rules, regulations, or instructions.
*
Yes
By submitting, I verify that my child is in 6th, 7th or 8th grade
Should be Empty: