JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Assalam Islamic School Registration Form
Registration and Book fee is $25.00/child
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Mother’s Name
*
Your answer
Mother's email
*
Your answer
Mother's Phone Number
*
Your answer
Father’s Name
*
Your answer
Father's email
*
Your answer
Father's Phone Number
*
Your answer
Address
*
Your answer
For emergency, please contact:
*
Mother
Father
Other:
Other contact name (if parent cannot be reached).
*
Your answer
Other contact phone number (if parent cannot be reached.
*
Your answer
Child’s Full name
*
Your answer
Child's Date of Birth
*
Your answer
Age
*
Choose
5
6
7
8
9
10
11
12
13
14
15
16
Gender
*
Male
Female
New student or returning student
*
New
Returning
Does your child have a medical condition or allergy that you want the school to be aware of?
*
Yes
No
If you answered “Yes", in the previous question, please list medical condition or allergy:
Your answer
Is there any other information about your child that you feel would be helpful for us to know? Please tell us below:
Your answer
SELECT PROGRAM CHOICE
*
Weekday program: Ages 5 - 13 Monday and Wednesday 5:00 - 7:00 PM
Weekday program Ages 13+ and Huffaz Tuesday and Thursday 5:00 - 7:00 PM
Weekend program Ages 5 - 13 Sunday 10:30 - 2:30 PM
Weekend program Ages 13+ and Huffaz 3:00 - 6:00 PM
Both Sunday and weekday Ages 5 - 13
Both Sunday and weekday Ages 13+ and Huffaz
Other:
Are you registering another child?
Yes
No
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Waterbury Islamic Cultural Center.
Report Abuse
Forms
