ICMC Karate Program Registration Form

ICMC Karate Program Registration Form
Parent/Guardian Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many children are you registering
Child 1 Name

First NameLast Name
Child 1 Date of Birth

MonthDayYear
Date
Child 1 Sex
Child 2 Name

First NameLast Name
Child 2 Date of Birth

MonthDayYear
Date
Child 2 Sex
Child 3 Name

First NameLast Name
Child 3 Date of Birth

MonthDayYear
Date
Child 3 Sex
Child 4 Name

First NameLast Name
Child 4 Date of Birth

MonthDayYear
Date
Child 4 Sex
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Any Allergies or Medical Conditions?

YesNo
Please give details
Do you want to add something about your child?
I, undersigned, agree with the following statements:

I am the parent/guardian of the child indicated above.If emergency medical care is needed and I am unavailable, I authorize the supervising teacher to seek medical treatment for my child.I am giving my permission to take my child's pictures for classroom projects and post them on the masjid website.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: