Idris Mosque Islamic Weekend School

Islamic Center of Washington Idriss Mosque School Program Registration and Application

MONTHLY FEES: $15.00 1st child / $10.00 each additional child

*Limited Need Based Scholarships Available

DATE: ______200___

Child’s Name ______Grade in School ______Birth Date ______Age_____ Sex ____M ___ F

List brothers/sisters to be registered for the school:

Name Grade in School Age Sex (M /F)

______

Address ______City ______State ______Zip ______

Mother/Guardian First & Last Name ______Pager/Cell ______

Address (if different than child’s) ______Phone (h) ______

Email: ______

Father/Guardian First & Last Name ______Pager/Cell ______

Address (if different than child’s) ______Phone (h) ______

Email: ______

Person Responsible for Payments: ______

EMERGENCY CONTACT

Name ______Relationship ______

Address ______Phone (h) ______Phone (w) ______

Please tell us what you want your child (ren) to learn in the Mosque school program?

______

What is the parent’s original language? ______

Does the child speak the parent’s original language? Yes _____ No _____ Do the parents speak English? Yes _____ No _____

Do the parents speak or read Arabic? Yes ______No _____ Neither ______

Does the child speak or read Arabic Speak _____ Read ______Neither _____

AUTHORIZATIONS

List the people who MAY sign for and pick up your child (ren):

1. ______Phone # ______

2. ______Phone # ______

3. ______Phone # ______

4. ______Phone # ______

List ANY people who MAY NOT sign for or pick up your child (ren):

1. ______

2. ______

3. ______

SIGNATURE

Parent/Guardian Name ______/______/______Printed Signature Date

APPLICATION SHOULD BE MAILED TO IDRISS MOSQUE, 1420 NE NORTHGATE WAY, SEATTLE, WA 98125 Or PLACE REGISTRATION IN ANY MOSQUE DONATION BOX ON PREMISE

NOTE: CHILD MAY NOT START PROGRAM UNTIL APPLICATION APPROVED AND PAYMENT ARRANGEMENTS

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