SCMS REGISTRATION PAGE

Family Name

Child/s First Name - Age - Grade *

Father's First Name *

Mother's First Name *

Phone *

Email *

Address *

City

State

Postal code

Primary Contact Person Info *

List 2 Relatives or Friends who may assume Temporary Care of your child if you cannot be reached (Emergency Contacts) *

Photo/Video Release *

I give consent for Masjid Freehaven SCMS to use photos and videos of my child for promotional purposes, including social media, website, and other media.

I Do Not give consent for Masjid Freehaven SCMS to use photos and videos of my child for promotional purposes.

Please observe our need for modest dress when in class. (Acknowledge) *

For the students: Females should have a head covering and ankle length dress, skirt or pants. If wearing pants please have a top that covers the hips. Males should wear loose fitting pants and shirts that are long enough so that their undergarments do not show when praying. For special programs (end-of-year program) boys should wear long pants.

Consent for Emergency Medical Care

If my child is ill or injured at school and needs emergency care and I cannot be reached, I hereby authorize Masjid Freehaven/SCMSS to make whatever arrangements deemed necessary. I agree to assume all responsibility and expenses, including transportation, incurred at this time. Emergency care will be provided at the closest hospital.

Please note any allergies or special conditions (for each child) :

Signature *

Clear

Date *

One Time Registration Fee/Donation for School Year

1 Child = $175

2 Children = $325

3 Children = $450

4 Children = $550

5 Children = $650

*Payment can be submitted on next page

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Masjid Freehaven. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.