Student Registration Form - Companions of Qur'an

Address *

Emergency Contact Information
Please Note: An emergency contact person must be someone other than the parents. It should be a neighbor or friend that can take your child in the event that we are unable to contact the parents.
Emergency Contact Name *

First Name Last Name
Relationship *
Emergency Contact Mobile Number *

Area Code Phone Number

Form Submission
Additional Comments
- I hereby release the Islamic Circle of North America and it's affiliates, its volunteers, and employees from all claims for damage arising from any activity, accident or injury which is caused by or arises from the participation of the applicant (s) names herein, during any program or in any facility where the program is held.
- I grant the Islamic Circle of North America and it's affiliates full rights to use the images of my "child" resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications.
Consent *

I have read and understood the above-mentioned rules and regulations and agree to abide by them. Send me new and announcments emails of the Islamic Community Centre of Milton.
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