DUS Islamic Education for Children                   
Registration Form
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Email *
Parent's Name (Last, First): *
Street Address:  *
Apartment/ Unit: 
City,  State, ZIP Code *
Cell Phone Number:  *
Email Address:  *
Emergency Contact:  *
Student Name (Last, First, MI):  *
Date of Birth:  *
Gender:  *
Special Needs?  *
If you have selected "Yes" as the answer to the previous question, then please indicate the types of accommodations needed.
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