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Contact Info

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Terms

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Payment

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Parent/Guardian's Email Address *

Parent/Guadian's Phone Number *

Parent/Guardian's Address

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

Emergency Contact Name (First and Last)

Emergency Contact Phone Number

Number of Students *

--Select Option-- 1 2 3 4 5

Student 1 Name *

Student 2 Name *

Student 3 Name *

Student 4 Name *

Student 5 Name *

Student 1 Age *

Student 2 Age *

Student 3 Age *

Student 4 Age *

Student 5 Age *

Primary Care Physician

Primary Care Physician Phone Number

Special Needs (if any):

Proper Islamic Attire: I acknowledge that students are required to adhere to the guidelines of proper Islamic attire during the Evening Makhtab Program. This includes modest clothing that covers the aurah (parts of the body that must be covered in accordance with Islamic teachings) for both male and female students. *

Agree

Disagree

Excellent Behavior: I understand that my child will be expected to exhibit excellent behavior throughout the Evening Makhtab Program. This includes showing respect towards teachers, fellow students, and staff members, as well as adhering to the rules and regulations set by the school. *

Agree

Disagree

Disruptive Behavior: I am aware that if my child engages in disruptive behavior that significantly hinders the learning environment or compromises the safety and well-being of others, the school reserves the right to take appropriate disciplinary action. Such actions may include verbal warnings, reflection sessions, and, in severe cases, expulsion from the program. The school will make a reasonable effort to communicate any concerns or disciplinary measures with me as the parent/guardian. *

Agree

Disagree

Health and Safety: I understand that while the school will take necessary precautions to ensure the health and safety of all students during the Evening Makhtab Program, accidents or unforeseen circumstances may occur. I agree to release the school, its staff, and volunteers from any liability in case of injury, illness, or loss of personal belongings during the program. *

Agree

Disagree

Emergency Medical Treatment: In the event of a medical emergency, I authorize the staff of the Evening Makhtab Program to seek necessary medical treatment for my child. I will be responsible for any expenses incurred for such treatment. *

Agree

Disagree

Photography and Media Release: I grant permission for the school to photograph or record my child during the Evening Makhtab Program for promotional or educational purposes. I understand that my child's identity may be kept confidential if necessary. *

Agree

Disagree

Parental Communication: I agree to maintain open and respectful communication with the school regarding my child's progress, concerns, or any changes in contact information. I understand that regular updates may be provided through messages, or other communication channels. *

Agree

Disagree

Signature (Enter full name below): *

$

One time payment of $125

$

One time payment of $200

$

One time payment of $275

$

One time payment of $350

$

One time payment of $425

Payment Summary

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