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AfterSchool Quran Program
Islamic Heritage Center AfterSchool Qur'an Program
ADMISSION APPLICATION
SECTION A: APPLICATION TYPE:-
APPLYING FOR:
Days - Please Check One
*
Mondays & Wednesdays
Tuesdays & Thursdays
Mondays - Thursdays
SECTION B: STUDENT INFORMATION:
First Name
*
Last Name
*
Birth Date
*
Email
*
Gender
*
====Please Select====
Male
Female
SECTION C:- CONTACT INFORMATION:
Street Address
*
City
*
State
*
Zip Code
*
Phone NO.
*
eMAIL
*
SECTION D:- IHC AFTER-SCHOOL QUR’AN AGREEMENT:
Parent Section (If The Student is Minor)
I, the undersigned parent or guardian of the above-named child(s) hereby grant permission for the student(s) to participate in all the activities and field trips of the Islamic Heritage Center After-School Qur’an Program. I, the undersigned parent or guardian of the above-named child(s) assume full responsibility for any injuries, damages, negligence and/or accidents, which may occur to the child(s) in or around the premises of the Islamic Heritage Center, or at, to, and/or from any Islamic Heritage Center activity locations. I also grant full permission to the Islamic Heritage Center to render a judgment and act accordingly concerning any form of medical attention, emergency first-aid, and/or hospitalization needed to the student(s) listed above in case of injury, accident, negligence or illness. I grant this permission to the school’s board, staff, teachers, volunteers, etc and/or medical personnel. I also claim responsibility of all medical expenses incurred for medical treatment. I hereby forever release and waive any rights, claims, demands, and/or actions that myself, my child, or anyone acting on behalf of my child’s(s) interest may have against the Islamic Heritage Center and all associates within (Board, staff, teachers, volunteers, etc) and to agree to hold harmless any liability against the Islamic Heritage Center, Board, staff, teachers, volunteers, etc, due to injuries, accidents, negligence, or any other circumstances arising from participation in this program.
Appreviation of Full Name
*
Full Name
*
Phone NO.
*
Date
*
SECTION E:- TUITION:
Please check the fee appropriate to your application below.
*
NEW APPLICATION FEE: $10 (NON-REFUNDABLE - Waived if Registered Before March 15th, 2010)
Mondays & Wednesdays: $100 (Monthly - NON-REFUNDABLE)
Tuesdays & Thursdays: $100 (Monthly - NON-REFUNDABLE)
Mondays - Thursday: $150 (Monthly - NON-REFUNDABLE)
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