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Maktab Registration

Number of students to attend *

1 First Name : *

1 Last Name: *

1 Age: *

1 Phone number: *

1 E-mail address: *

2 First Name :

2 Last Name:

2 Age: *

2 Phone number:

2 E-mail address:

3 First Name :

3 Last Name:

3 Age: *

3 Phone number:

3 E-mail address:

4 First Name :

4 Last Name:

4 Age: *

4 Phone number:

4 E-mail address:

5 First Name :

5 Last Name:

5 Age: *

5 Phone number:

5 E-mail address:

6 First Name :

6 Last Name:

6 Age: *

6 Phone number:

6 E-mail address:

7 First Name :

7 Last Name:

7 Age: *

7 Phone number:

7 E-mail address:

Father"s Name *

Father"s Email *

Mother"s Name *

Mother"s Email *

Street address: *

City: *

State: *

Zip code: *

Emergency Contact *

Relationship to Student *

Emergency Contact # *

Medical Info we should know about (allergies, conditions, etc.) *

Authorization for Emergency Medical Attention MANW will do their best to contact family members (parents/guardians) in case of medical emergency. However, if no one can be reached in a timely manner, under discretion of the MANW Administration, then professional medical attention will be sought. I hereby give consent for MANW"s Administration to secure any and all necessary medical care for the registered student in case of a medical emergency. I further acknowledge and understand that MANW will not be responsible for any charges or expenses incurred as a result of the medical care given. I bear full responsibility for all related expenses.

Signature - Sign if printing out or enter your e-mail address as your electronic signature (must be parent or legal guardian if under 18). *

Consent Parents/Guardians are responsible for making arrangement to have their child(ren) picked up after the program. I hereby recognize that MANW Adminstration is not responsible for any children after program hours, and I take full responsibility for making arrangements to have my child(ren) picked up.

Signature - Sign if printing out or enter your e-mail address as your electronic signature (must be parent or legal guardian if under 18). *

Registration fees are due each 3-month term (quarterly). The terms are from September – November, December – February, and March – June.

1 Student - $225.00 per quarter (total fees for the year – $675.00)

2 Students - $375.00 per quarter (total fees for the year – $1,125.00)

3 Students - $480.00 per quarter (total fees for the year – $1,440.00)

4 or more Students - free

Registration Fee *

Method of payment

check monthly auto payment via checking account

Bank Account Routing # *

Bank Account Account # *

Authorization

I hereby authorize MANW to initiate donation(s) according to my choices above.

Signature - Sign if printing out or enter your e-mail address as your electronic signature (must be parent or legal guardian if under 18). *

Donations are tax exempt. We are a 501(c)3 non-profit organization. Muslim Association of the North West (MANW) 5507 238th St. SW Mountlake Terrace, WA 98043 (425) 776-6162 http://farooqmasjid.org