ICOC YOUTH ISLAMIC STUDIES REGISTRATION
First Day:  September 7, 2024 @ 10:30am, then Studies at 11:00 am
Regular Schedule: Saturdays 11:00am - 1:45pm
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Masjid Address: 15020 Johns Lake Rd, Clermont, FL 34711
Contact: Imam Husman (407) 267-8320 or Sy Khan at icoc.p2@gmail.com
Parent/Guardian First & Last Name: *
Parent/Guardian Contact Number: *
Parent/Guardian Email Address: *
Your Relationship to Student: *
Emergency Contact Name & Phone Number (other than Parents/Guardians): *
STUDENT 1 - First & Last Name: *
STUDENT 1 - Date of Birth (mm/dd/yyyy): *
STUDENT 1 - Gender: *
STUDENT 1 - Email Address:
STUDENT 2 - First & Last Name (additional child):
STUDENT 2 - Date of Birth (mm/dd/yyyy):
STUDENT 2 - Gender:
Clear selection
STUDENT 2 - Email Address:
STUDENT 3 - First & Last Name (additional child):
STUDENT 3 - Date of Birth (mm/dd/yyyy):
STUDENT 3 - Gender:
Clear selection
STUDENT 3 - Email Address:
Street Address: *
City: *
State:  *
Zip: *
Primary Language Spoken at Home: *
Dietary Restrictions/Allergies
Do/Does the student(s) require any accommodations? *
Any additional information:
Permission and Agreements *
I do not give permission for the student/students for the following activities:
I/We understand that there is a fee for registration & books. Payment is receivable through the masjid website via the donation link.
(If anyone needs assistance to pay, please check the appropriate box.) *
Required
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