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MOMMY & ME

September 29, 2024 admin

Dar Ul Imaan Presents

MOMMY AND ME

A nurturing space where mothers can strengthen their bond with their children while exploring the teachings of Islam

EVERY SATUTDAY
Starting Saturday October 5, 2024.

Ages : 2-4 years

Time : 11:00 am to 1:00 pm

Fee:
one time registration -$10
$25/per child for 4 weeks

جزاك الله خيراكثيرا

To register fill form below

Dar Ul Imaan Institute - Mommy and Me Form

Registration Form

Step 1 of 8

12%

Student Information
Please Provide Student information.
Number of Children*
- One
- Two
You can apply for up to two children using this one Application form. if number of children are greater than 2, please fill out for the remaining children in separate Application form.
1st Child's Name*
FirstLast
Date of Birth*
Gender*
- Male
- Female
Health Card no*

2nd Child's Name*
FirstLast
Student Information
Please Provide 2nd Student information.
Date of Birth*
Gender*
- Male
- Female
Health Card no*

Mother’s Information
Please Provide student's mother information.
Mother's Name*
Home Phone*
Work Phone*
Street Address*
City, province, postal code*
Other parent ?*
- Yes
- No

2nd Guardian Information
Please Provide student's 2nd Guardian information.
Parent's / 2nd Guardian Name*
Home Phone*
Work Phone*
Street Address*
City, province, postal code*

Alternative Emergency Contacts
Please Provide Alternative Primary Emergency Contact information.
Primary Emergency Contact
Home Phone
Work Phone
Address
City, ST ZIP Code

Alternative Emergency Contacts
Please Provide Alternative Secondary Emergency Contact information.
Secondary Emergency Contact
Home Phone
Work Phone
Address
City, ST ZIP Code

Medical Information
Please Provide Student's Medical Information.
Hospital/Clinic Preference
Physician’s Name
Phone Number
Allergies/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 Summer Camp, as long as normal safety procedures have been taken..
Parent’s/Guardian’s Signature*
Date*
Phone
This field is for validation purposes and should be left unchanged.