Quran Circle Registration
June 9th 2017
Parent/Guardian Name
*
First Name
Last Name
E-mail
*
How many adults (over 19) are in your party?
*
1
2
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6
7
How many youth (ages 1-19) are you registering?
*
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2
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6
7
Child #1 Name
*
First Name
Last Name
Child #1 Age
*
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2
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18
Child #2 Name
*
First Name
Last Name
Child #2 Age
*
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2
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19
Child #3 Name
*
First Name
Last Name
Child #3 Age
*
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2
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18
Child #4 Name
*
First Name
Last Name
Child #4 Age
*
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2
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5
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18
Child #5 Name
*
First Name
Last Name
Child #5 Age
*
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2
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18
Child #6 Name
*
First Name
Last Name
Child #6 Age
*
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2
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5
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18
Child #7 Name
*
First Name
Last Name
Child #7 Age
*
1
2
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4
5
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7
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9
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11
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14
15
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18
Submit
I, the parent or legal guardian of the child(ren) registered above, release Next Wave Muslim Initiative (NWMI), and their respective officers and staff from any liability arising from my child(ren)'s participation in this program. In the event that my child(ren) experience(s) illness or injury requiring medical attention and I am not on-site, I authorize NWMI staff to provide any reasonable treatment that they deem necessary, including transport to a medical facility.
*
I agree
Should be Empty: