Muhammadi Masjid

Student Name*

Date of Birth:*

Home Address:*

Email Address:*

Father's Name:*

Father's Primary Number:*

Mother's Name:*

Mother's Primary Number:*

Emergency Contact (Name, email address, phone number):*

I/we consent for my child/children, listed above, to participate in the activities applied for, at Muhammadi Masjid.*

Yes No

I/we have inspected or have waived inspection of the premises located at 681 Elmont Road, Elmont, NY 11003, where the activities shall take place and have found them to be of a reasonably safe nature & otherwise suitable for the activities, which are to take place there.*

Yes No

I/we waive any rights which may accrue to our self or our child under any cause of action which may arise from any negligent and/or intentional act(s) on the part of the Muhammadi Masjid, its board members, management committee, employers, staff or volunteers.*

Yes No

I/we take responsibility for providing transportation for my child immediately at the conclusion of any program for that day.*

Yes No

I/we acknowledge that no one will be supervising my child on the premises except for 5 minutes before the start of the activities, and 5 minutes after the conclusion of the activities.*

Yes No

Parent E-sign:*

Today's Date:*

Maktab Program

786 Muhammadi Masjid

MUHAMMADI MASJID MAKTAB PROGRAM

Muhammadi Masjid Maktab Program is from Monday to Friday, 5:30 PM to 7:30 PM.

Monthly Fees: $70 for First Child & $60 for Second Child