Pre-Registration FormChildren Programs Parent/Guardian Full Name * First Name Last Name Parent/Guardian Email Address * Phone Number * (###) ### #### Relationship to Child * Father Mother Legal Guardian Other Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Child Full Name * First Name Last Name Child Date of Birth * MM DD YYYY Child Age * Child Gender * Male Female Entering School Grade * Please Select One Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th Special Needs or Accommodations (if applicable) leave blank or enter N/A if not applicable Program Selection * Select All Programs That You Have Interest In Full-Time Hifz School (Pre-K to 8th Grade) After School Program (Tuesdays and Saturdays) Weekend Program (Saturdays and Sundays) Additional Information Please provide any additional information you'd like us to know about your child, their interests, or their goals in attending our programs. Emergency Contact Full Name * Please provide at least one emergency contact other than the parent/guardian listed above. First Name Last Name Relationship to Child * Father Mother Legal Guardian Other Emergency Contact Phone Number * (###) ### #### Once you click Send, you will be rediected to pay your $50 application fee. Thanks! Thank you!
