Islamic Essentials
A Foundation in Faith for Every Muslim Child & Teen
Registration Form for Boys Only
Student Information
Student First Name
*
Student Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Guardian
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
*
City
*
State
*
Zip Code
*
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Relationship to Student
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical/Health Information
Does your child have any allergies?
*
Yes
No
If yes, please describe allergies
Does your child have any medical conditions we should be aware of?
*
Yes
No
If yes, please describe
Terms & Agreement
Permission for Child to Participate in the Program
*
I give permission for my child to participate in the program
Agreement to Pick Up Child Promptly at 6:30 PM Each Session
*
I agree to pick up my child promptly at 6:30 PM each session
Authorization for Sunnah Academy Staff to Administer First Aid if Necessary
*
I authorize Sunnah Academy staff to administer first aid if necessary
Hold Harmless Agreement - I, the undersigned parent/guardian, hereby agree to hold harmless, release, and indemnify Sunnah Academy, its staff, volunteers, and representatives from any and all liability, claims, damages, or injuries that may arise from my child's participation in the Islamic Essentials after school program, including but not limited to accidents, injuries, or incidents that may occur during program hours or while traveling to and from the program.
*
I have read and agree to the Hold Harmless Agreement above
Parent/Guardian Signature
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payment Fees
*
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Monthly Tuition
Monthly tuition per student
$150.00
$
150.00
One-time Registration Fee
One-time registration fee per student
$50.00
$
50.00
Book Fee
Book fee per student
$50.00
$
50.00
Payment Methods
Debit or Credit Card
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Submit
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