Student's Name *

First Name

Last Name

Student's Date of Birth *

MM

DD

YYYY

Is your child fully potty trained? *

(Note: All Weekend School students are required to be fully potty trained to attend.)

YES

NO

Will any siblings be attending the same weekend school location this semester? *

Yes

No

Parent/Guardians Name: *

First Name

Last Name

Home Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does this child take any medications? *

Yes

No

Does this child have any allergies? *

Yes

No

Does this child have any other health concerns our Weekend School staff should be aware of? *

Yes

No

Emergency Contact Name 1: *

(Note: Only people listed as the student's emergency contact will be allowed to pick up student from Weekend School)

First Name

Last Name

Emergency Contact Phone 1 *

(###)

###

####

Emergency Contact Name 2:

First Name

Last Name

Emergency Contact Phone 2

(###)

###

####

Please check “YES” that you understand this program is open ONLY to Muslim children between the ages of 6-12 with special needs and that monthly tuition is $100 (unless otherwises specified). *

Yes