<p> Islamic Center of Washington Idriss Mosque School Program Registration and Application</p><p>MONTHLY FEES: $15.00 1st child / $10.00 each additional child</p><p>*Limited Need Based Scholarships Available</p><p>DATE: ______200___</p><p>Child’s Name ______Grade in School ______Birth Date ______Age_____ Sex ____M ___ F </p><p>List brothers/sisters to be registered for the school:</p><p>Name Grade in School Age Sex (M /F)</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Address ______City ______State ______Zip ______</p><p>Mother/Guardian First & Last Name ______Pager/Cell ______</p><p>Address (if different than child’s) ______Phone (h) ______</p><p>Email: ______</p><p>Father/Guardian First & Last Name ______Pager/Cell ______</p><p>Address (if different than child’s) ______Phone (h) ______</p><p>Email: ______</p><p>Person Responsible for Payments: ______</p><p>EMERGENCY CONTACT </p><p>Name ______Relationship ______</p><p>Address ______Phone (h) ______Phone (w) ______</p><p>Please tell us what you want your child (ren) to learn in the Mosque school program?</p><p>______</p><p>______</p><p>What is the parent’s original language? ______</p><p>Does the child speak the parent’s original language? Yes _____ No _____ Do the parents speak English? Yes _____ No _____</p><p>Do the parents speak or read Arabic? Yes ______No _____ Neither ______</p><p>Does the child speak or read Arabic Speak _____ Read ______Neither _____</p><p>AUTHORIZATIONS</p><p>List the people who MAY sign for and pick up your child (ren):</p><p>1. ______Phone # ______</p><p>Address ______City ______State ______Zip ______</p><p>2. ______Phone # ______</p><p>Address ______City ______State ______Zip ______</p><p>3. ______Phone # ______</p><p>Address ______City ______State ______Zip ______</p><p>4. ______Phone # ______</p><p>Address ______City ______State ______Zip ______</p><p>List ANY people who MAY NOT sign for or pick up your child (ren):</p><p>1. ______</p><p>2. ______</p><p>3. ______</p><p>SIGNATURE</p><p>Parent/Guardian Name ______/______/______Printed Signature Date</p><p>APPLICATION SHOULD BE MAILED TO IDRISS MOSQUE, 1420 NE NORTHGATE WAY, SEATTLE, WA 98125 Or PLACE REGISTRATION IN ANY MOSQUE DONATION BOX ON PREMISE</p><p>NOTE: CHILD MAY NOT START PROGRAM UNTIL APPLICATION APPROVED AND PAYMENT ARRANGEMENTS</p><p>MADE OR PAYMENT RECEIVED IDRISS MOSQUE School Registration/ Application Page 2 of 2</p>