Dar-ul-Imaan Institute – Program Registration for Kids

Dar-ul-Imaan Institute - Kid's School Program Registration

Registration form for all of Dar-ul-Imaan Institute's programs for kids.

Step 1 of 5

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Parent/Guardian Information
Please provide information below on the child's parent/guardian(s).
Primary Parent/Guardian's Full Name*
Please list the first point of contact that we should reach out to for the child's parent/guardian. Please provide the below information for this primary contact.
Primary Phone Number (Home or work)*
xxx-xxx-xxxx
Secondary Phone Number (Home or work)*
If the same as above, please write N/A.
Email Address*
It is important that we have an email on file that is checked regularly for communication regarding your child.
Street Address*
City, province, postal code*
More than one Parent/Guardian?*
- Yes
- No
If there is a secondary parent/guardian that should be contacted for communication regarding the child, please choose YES and then complete the questions below. If NO, then please skip the remaining questions.
Secondary Parent/Guardian's Name
Primary Phone Number (Home or work)
xxx-xxx-xxxx
Secondary Phone Number (Home or work)
If the same as the above, please write N/A.
Street Address
City, province, postal code

Alternative Emergency Contact Information
In the case of an emergency, we will contact the primary (and secondary) parent/guardian on file. If you only provided contact information for a primary parent/guardian, we require an additional alternative emergency contact.
Alternative Emergency Contact #1 Full Name
Primary Phone Number (Home or work)
Secondary Phone Number (Home or work)
Street Address
City, province, postal code
Alternative Emergency Contact #2 Full Name
Primary Phone Number (Home or work)
Secondary Phone Number (Home or work)
Street Address
City, province, postal code

Medical Information
Please provide the child's medical information.
Hospital/Clinic Preference
Please provide the name and full address of the hospital/clinic.
Physician’s Full Name
Physician's Office Phone Number

Authorizations and Consent
Dar-ul-Imaan Institute is excited for your child to join our programs. Please carefully review and sign the below consent forms in order to complete the application form. All authorizations and consents listed below are for the child listed in this registration form.
Dar-ul-Imaan Institute takes photographs and videos of its programs for the following purposes: 1) Promotional Materials: These may include brochures, flyers, and advertisements that showcase the activities and environment of our programs 2) School Website: Images and videos may be posted on our official website to provide insight into the student experience 3) Social Media: We may share visual content on social media platforms for educational and promotional purposes
Media Authorization*
- I give full consent of my child’s photographs and videos to be used for all the above purposes.
- I do not consent to my child being photographed and videoed.
Primary Parent/Guardian’s Signature*
This consent must be signed by the primary parent/guardian that has been listed on the application form.
Date*
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(s) or emergency contacts can be reached in the case of an emergency.
Primary Parent/Guardian’s Signature*
This consent must be signed by the primary parent/guardian that has been listed on the application form.
Date*
I waive all rights, liabilities, claims and/or actions against all staff, volunteers, and affiliates part of Dar ul Imaan Institute Inc. in case of accident during activities related to the registered program where due safety measures have been implemented.
Primary Parent/Guardian’s Signature*
This consent must be signed by the primary parent/guardian that has been listed on the application form.
Date*
I give permission for my child to play outside in and around the playground at Dar-ul-Imaan Institute. I understand that appropriate supervision will be provided, but there are inherent risks associated with outdoor play.
Primary Parent/Guardian’s Signature*
This consent must be signed by the primary parent/guardian that has been listed on the application form.
Date*
In the event of an incident, when necessary, I authorize the staff at Dar-ul-Imaan Islamic Montessori School to change my child’s diaper. I understand that every effort will be made to ensure my child’s comfort and privacy during diaper changes.
Primary Parent/Guardian’s Signature*
This consent must be signed by the primary parent/guardian that has been listed on the application form.
Date*
I agree to pay all tuition fees on-time and prior to the start of the program. I understand that all fees are non-refundable.
Primary Parent/Guardian’s Signature*
This consent must be signed by the primary parent/guardian that has been listed on the application form.
Date*
Comments
This field is for validation purposes and should be left unchanged.

Dar-ul-Imaan Institute - Kid's School Program Registration

Step 1 of 5

Student Information

Parent/Guardian Information

Alternative Emergency Contact Information

Medical Information

Authorizations and Consent