REGISTRATION FORM
Please fill out all the information and sign the release agreements at the bottom and click the submit button.
Sign in to Google to save your progress. Learn more
NOOR TILAWAH
Captionless Image
MM
/
DD
/
YYYY
FATHER'S NAME *
FATHER'S PHONE NUMBER *
FATHER'S EMAIL *
MOTHER'S NAME *
MOTHER'S PHONE NUMBER *
MOTHER'S EMAIL *
EMERGENCY CONTACT *
EMERGENCY CONTACT PHONE *
CHILD # 1 FULL NAME *
DATE OF BIRTH *
MM
/
DD
/
YYYY
GENDER *
SCHOOL GRADE *
Allergies and/or Special Medical Care *
CHILD# 2 FULL NAME
DATE OF BIRTH
MM
/
DD
/
YYYY
GENDER
Clear selection
SCHOOL GRADE
Allergies and/or Special Medical Care
CHILD# 3 FULL NAME
DATE OF BIRTH
MM
/
DD
/
YYYY
GENDER
Clear selection
SCHOOL GRADE
Allergies and/or Special Medical Care
CHILD# 4 FULL NAME
DATE OF BIRTH
MM
/
DD
/
YYYY
GENDER
Clear selection
SCHOOL GRADE
Allergies and/or Special Medical Care
Release of Liability and Authorization for Treatment
I hereby grant permission for my child(ren) to participate in the NOOR TILAWAH . Any health concerns or consideration should be acknowledged in writing. In the event I cannot be reached in an emergency, I hereby give my permission to a physician selected by the staff to secure and administer treatment, including hospitalization. I consent to an ambulance being called to transport the child(ren), if necessary, and further understand that I am fully liable for all costs incurred for the transportation. I further agree to hold harmless AIW, NICC and/or NOOR TILAWAH, whom are conducting the activities, from any and all claims, suits, losses or related causes of action for damages, including but not limited to such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities.
I RELEASE ALL LIABILITY AND GRANT AUTHORIZATION FOR TREATMENT. *
Photography Consent/Release Agreement
I hereby grant permission to the Noor TILAWAH of Noor Islamic Cultural Center - American Islamic Waqf, to take and use photographs and/or digital images of my child(ren) for use in Noor TILAWAH, NICC-AIW publication and/or presentations. These materials might include but are not limited to printed or electronic publications, website or other electronic communication. I further agree that my child's name and identity may be revealed in descriptive text and/or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negative, prints, digital reproduction shall be the property of the Noor TILAWAH.
PHOTOGRAPHY CONSENT/RELEASE AGREEMENT *
PROGRAM POLICY
1. PAYMENT ARE DUE ON THE FIRST WEEK OF THE MONTH, AFTER THAT A $25 FEE WILL BE APPLIED TO EVERY LATE PAYMENT, NO EXCEPTION.
2. STUDENTS SHOULD HAVE PROPER ATTIRE FOR MASJID AND SALAT
3. BE ON TIME, BE COURTEOUS, BE RESPECTFUL
4. PARENTS ARE TO PICK UP THE STUDENTS AT THE TIME OF DISMISSAL. A FEE WILL BE APPLIED TO EACH MINUTE THE PARENTS ARE LATE FOR PICK UP AT THE RATE OF $1/MIN.
5. PLEASE CONTACT US IF YOUR STUDENT IS SICK, WILL NOT BE ATTENDING, OR WILL BE GOING ON VACATION
6. PLEASE LET US KNOW IF YOU DECIDE TO REMOVE YOUR STUDENT FROM THE PROGRAM.
7. THE BASEMENT DOOR WILL BE LOCKED FOR SECURITY REASON AFTER THE START OF THE CLASSES. LATE STUDENTS WILL NEED TO BE LET IN BY ONE OF OUR ASSISTANT
8. STUDENTS WILL BE ACCOMPANIED AT ALL TIME DURING THEIR PRESENCE AT THE MASJID UNTIL DISMISSAL FROM THE CLASS, UNLESS THEY NEED TO USE THE RESTROOM.
9. BREAKS WILL BE TAKEN AT THE TIME OF SALAT NOT TO EXCEED 15 MIN.
10. WE WILL CONTACT YOU TO INFORM YOU OF ANY SCHEDULE CHANGES OR CANCELLATIONS.
11. THERE WILL BE ZERO TOLERANCE FOR BAD BEHAVIOR:
      * FIRST TIME OFFENDERS: A NOTICE WILL BE SENT TO THE PARENTS AND THE BEHAVIOR WILL BE ADDRESSED
         APPROPRIATELY.
      * SECOND TIME OFFENDERS: A MEETING WITH THE PARENTS WILL BE REQUESTED AND A ONE-DAY REMOVAL
         FROM THE PROGRAM WILL BE IMPLEMENTED.
      * THIRD TIME OFFENDERS: A MEETING WITH THE PARENTS AND DISMISSAL OF THE STUDENT FROM THE
         PROGRAM.    

BY SIGNING THIS DOCUMENT YOU ARE AGREEING TO OUR POLICY *
Choose from the below *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy