Islamic Weekend School Registration Form

Islamic Weekend School Registration Form

Sundays, 10am - 2pm
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Current Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #3 Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up #1 Name

First NameLast Name
Authorized Pick-Up #2 Name

First NameLast Name
Authorized Pick-Up #3 Name

First NameLast Name
Authorized Pick-Up #4 Name

First NameLast Name
Preferred Medical Facility
Name of Physician/Pediatrician

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have any allergies or medical conditions?
If Yes, please give details
Does your child have an IEP or 504 Plan?
If Yes, please give details:
Is there a custody order we should know about?
If Yes, please give details:
I, undersigned, agree with the following statements:
Date

MonthDayYear
Date

My Products

Madressa Fee

$60.00

Enter coupon

Total

Credit Card

Should be Empty: