MGN Registration
Student Name
*
First Name
Middle Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Gender
*
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Status
Afghan Arrival: arrived after July 31st,2021
Not Applicable
Education
*
Please Select
Freshman
Sophmore
Junior
Senior
Name of Highschool
*
Does your highschool have an active MSA?
*
Allergies (if none put N/A)
*
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Parent/Guardian Information
Our parent participation is crucial in the success of our program. Please input your information as we will be having an online orientation for the parents before the program. When the program is completed, we ask that parents make themselves available for MGN Commencement.
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relation to Student
*
Please Select
Mother
Father
Legal Guardian
Emergency Contact
Please put down the best contact if the parent/guardian above is not reachable.
Parent/Guardian Name
*
First Name
Last Name
Relation to Student
*
Please Select
Mother
Father
Grandma
Grandpa
Legal Guardian
Aunt
Uncle
Brother
Sister
Other
Phone Number
*
Please enter a valid phone number.
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Program Specific
In this section, please answer these questions to the best of your ability.
What region will you attend?
*
Please Select
Rancho Masjid (Ansaar Academy)
Islamic Institute of Orange County (IIOC)
Santa Barbara
Islamic Society of West Valley (ISWV)
Other
Are you involved in any clubs or extra curriculars?
*
Do you attend a masjid?
*
What Masjid?
*
Please explain why you are interested in becoming a Muslim Game Changer.
*
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Payment
I acknowledge to pay the $50 MGN Registration Fee through the CAIR-LA website. Please select $50 and choose MGN fee in the dropdown menu. In the notes section please write "MGN - [Insert Masjid]" I will pay using the link after I hit submit.
Submit
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