ICBC Education Program
Al Furqan Academy - Student Registration Form 2018-2019
Student Information
Student's Full Name *
Your answer
Students's DOB *
Your answer
Student's Grade *
Your answer
Parent Information
Parent's Name *
Your answer
Primary Email *
Your answer
Secondary Email
Your answer
Parent's Mobile Number *
Your answer
Alternate Mobile Number
Your answer
General Information
Fee for the program is $50 per child per month
Fees are due at time of registration and the first of every month
Emergency Care Authorization - Please Read *
I, the undersigned, agree to indemnify, hold harmless and defend ICBC and the Executive Board, the Shura Council, the education program teachers, individual members, coordinators & volunteers, Williamson County, the Williamson County Board of Education, School or Community Use of Public Facilities, and all of their officials, employees, members and agents, for any loss, cost, damage, claim or other expense suffered or incurred that may arise during or be caused in any way by program activities or use or occupancy of Masjid property, including any loss or injury of any kind alleged to be the result of any negligence by ICBC, ICBC administration, teachers, individual members & volunteers. As a parent/legal guardian of the minor(s) listed above, I hereby grant permission for these student(s) to participate in all activities of the Education programs. I assume full responsibility for any injuries or damages which may occur to these student(s), in, on, or about the premises of ICBC, or arising out of its activities, wherever it may be, including transportation to and from ICBC and its activities. I further grant permission to ICBC administration, teachers or individual members & volunteers to provide emergency first aid and/or hospitalization to these student(s) in case of injury or illness as deemed appropriate by ICBC. Any medical expenses incurred for medical treatment shall be my responsibility. By checking box below, you agree to above.
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