Youth/Children Registration Form

Student(s) Information

First Name, Last Name

For additional name fields, click the plus icon. To remove a field, click the minus icon.

Home/Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Has your child ever had psychological testing or been screened for academic difficulties or learning disabilities?

Yes

No

If yes, please explain:

Does your child have any health concerns (allergies, asthma, diabetes, etc.)?

Yes

No

If yes, please explain:

Is your child taking any prescription or non-prescription medication?

Yes

No

If yes, please explain:

Father's Information

Name

Phone Number

Email

Home/Mailing Address (if different than above)

Address Line 1

Address Line 2

City

State

Zip Code

Country

Mother's Information

Name

Phone Number

Email

Home/Mailing Address (if different than above)

Address Line 1

Address Line 2

City

State

Zip Code

Country

(OPTIONAL) Emergency Contacts (other than parents):

First Name

Middle Name

Last Name

First Name

Middle Name

Last Name

First Name

Middle Name

Last Name

Authorization & Acknowledgement

I hereby authorize the staff representing Masjid Ibraaheem to give consent for any and all necessary emergency medical and first aid care for my child while he/she is in the custody of Masjid Ibraaheem. (Ambulance fees and/or health care costs are the responsibility of the parent/guardian.

Yes

No

I hereby attest that all information in this application is true and up-to-date. I understand that if this information is not found to be accurate, my child’s place in Masjid Ibraaheem may be forfeited.

Yes

No

I permit Masjid Ibraaheem to take pictures of my child and to use those pictures as necessary. I understand that my child’s name will not be used in the pictures.

Yes

No

I understand that I have to pay the necessary fees (depending on the selected program) to complete the registration process.

Yes

No

I consent to have this website store my submitted information so they can respond to my inquiry

Payment Information

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For discounts on more than two siblings, please contact us at seminary@masjidibraaheem.com for more information.

Number of Student(s)

Select program

Hifdh Program

$150.00 for each month

Evening School

$50.00 for each month

Sunday School

$40.00 for each month

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Youth/Children Registration Form

Student(s) Information

Father's Information

Mother's Information

(OPTIONAL) Emergency Contacts (other than parents):

Authorization & Acknowledgement

Payment Information

Links

Support

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