Assalam Islamic School Registration Form
Registration and Book fee is $25.00/child
* Required
Email address
*
Your email
Date
*
MM
/
DD
/
YYYY
Mother’s Name
*
Your answer
Mother's email
*
Your answer
Mother's Phone Number
*
Your answer
Father’s Name
*
Your answer
Father's email
*
Your answer
Father's Phone Number
*
Your answer
Address
*
Your answer
For emergency, please contact:
*
Mother
Father
Other:
Other contact name (if parent cannot be reached).
*
Your answer
Other contact phone number (if parent cannot be reached.
*
Your answer
Child’s Full name
*
Your answer
Child's Date of Birth
*
Your answer
Age
*
Choose
5
6
7
8
9
10
11
12
13
14
15
16
Gender
*
Male
Female
New student or returning student
*
New
Returning
Does your child have a medical condition or allergy that you want the school to be aware of?
*
Yes
No
If you answered “Yes", in the previous question, please list medical condition or allergy:
Your answer
Is there any other information about your child that you feel would be helpful for us to know? Please tell us below:
Your answer
SELECT PROGRAM CHOICE
*
Weekday program: Ages 5 - 13 Monday and Wednesday 5:00 - 7:00 PM
Weekday program Ages 13+ and Huffaz Tuesday and Thursday 5:00 - 7:00 PM
Weekend program Ages 5 - 13 Sunday 10:30 - 2:30 PM
Weekend program Ages 13+ and Huffaz 3:00 - 6:00 PM
Both Sunday and weekday Ages 5 - 13
Both Sunday and weekday Ages 13+ and Huffaz
Other:
Are you registering another child?
Yes
No
Clear selection
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This form was created inside of Waterbury Islamic Cultural Center.
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