Darulimaan Weekend School Darulimaan Weekend School Weekend School Registration Form Step 1 of 10 10% Student InformationPlease Provide Student information. Number of Children*OneTwoThreeYou can apply for up to three children using this one Application form. if number of children are greater than 3, please fill out for the remaining children in separate Application form.1st Child's Name*FirstLastDate of Birth* Health Card no*Gender*MaleFemale Student InformationPlease Provide 2nd Student information. 2nd Child's Name*FirstLastDate of Birth* Gender*MaleFemaleHealth Card no* Student InformationPlease Provide 3rd Student information. 3rd Child's Name*FirstLastDate of Birth* Gender*MaleFemaleHealth Card no* Select School Locations2 Locations : Mississauga and Brampton Select School*Saturday : 10:00 - 2:00 pmWoodlands Secondary School3225 Erindale Station Road, mississaugaON L5C 1Y5Starting from Saturday September 16, 2017 Jean Augustine secondary SchoolElbern Markell driveBrampton ON L6X 5L3Starting from Saturday September 30, 2017 Milton Weekend School Parent / Guardian InformationPlease Provide student's Guardian information. Parent's / Guardian Name*Home Phone*Email*Work Phone*Street Address*City, province, postal code*More than one Guardian?*YesNo 2nd Guardian InformationPlease Provide student's 2nd Guardian information. Parent's / 2nd Guardian Name*Home Phone*Work Phone*Street Address*City, province, postal code* Alternative Emergency ContactsPlease Provide Alternative Primary Emergency Contact information. Primary Emergency ContactHome PhoneWork PhoneAddressCity, ST ZIP Code Alternative Emergency ContactsPlease Provide Alternative Secondary Emergency Contact information. Secondary Emergency ContactHome PhoneWork PhoneAddressCity, ST ZIP Code Medical InformationPlease Provide Student's Medical Information.Hospital/Clinic PreferencePhysician’s NamePhone NumberAllergies/Special Health Considerations I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.Parent’s/Guardian’s Signature*Date* I give permission for my child to go on field trips (if any). I release Darulimaan Institute and individuals from liability in case of accident during activities related to Weekend School, as long as normal safety procedures have been taken..Parent’s/Guardian’s Signature*Date* CommentsThis field is for validation purposes and should be left unchanged.
