Parent Enrollment Form
Assalaamu alaikum parents!

In order to enroll your child in Dose of Deen, we kindly request that you complete a short survey. This survey will provide us with important information about your child and their interests, which will help us to better serve them. As a reminder, this program is for 4th to 8th graders only. 

Please take a few moments to fill out the survey. We appreciate your time and consideration, and we look forward to the opportunity to work with your child.

 If you have any questions, please email youth.admin@masnewyork.org.
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Parent 1 First and Last Name  *
Parent 1 Email *
Parent 1 Phone Number *
Parent 2 First and Last Name *
Parent 2 Email *
Parent 2 Phone Number *
Home Address *
Your Child's First and Last Name *
Your Child's Age *
Your Child's Gender *
What goals do you have for your child (academic, deen, and/or personal)? *
What are your child's strengths? *
Required
What does your child struggle with? *
Required
How much screen time does your child observe daily (tv, games, etc)? *
Has your child been previously or currently enrolled in any other programs? *
Outside of school, what does your child participate in? *
Required
Does your child have any learning disabilities?
*Please note that this will allow our mentors to gain a better understanding of your child.
 *
Required
What is your child's personality type? *
If all spots are filled, would you like to add your child to the waitlist? *
Do you have any concerns? *
For our brothers' circles, please select a day and time for weekly in-person group sessions below.
*Please note that you should only fill this out if you are enrolling your son. 
 *
For our sister's circle, please confirm the day and time for weekly in-person group sessions below.
*Please note that you should only fill this out if you are enrolling your daughter.
 *
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