Register 2012 Summer School
Parent Name *
Please enter your first and last name
Your answer
Parent Address *
Street Address, City, State & Zip
Your answer
Parent Email Address
Your answer
Parent Primary Phone Number *
Your answer
Who is this Child's Emergency Contact *
Please List Name, Phone Number, and Email Address
Your answer
Child Name *
If you are registering multiple children, please note you will have to complete this form again
Your answer
Child Birth Date *
mm/dd/yyyy
Your answer
Any medical condition that we should be aware of
e.g. allergies
Your answer
How much Salah Has Your Child Memorized
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