Note: Please fill entire form in order to enroll.

Parent information

Parent Email Address ***Valid email address required***:

Parent Full Name:

Parent Phone #:

Emergency contact information

Emergency ContactName:

Emergency Contact Phone #:

Photography Consent

Photography Consent: --Please Select-- Yes No

Please enter your Child(ren) Information*

• Fee will be auto calculated:
• Click "Add new child" button below to add your child(ren)
• Fee for 1 Child : $600
• Fee for 2 Children : $900
• Fee for 3 or more Children : $1,200

Total Amount($):

Add new child

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CHAGRIN VALLEY ISLAMIC CENTER - Add/Update Latest Update Section

Id:
Child Full Name:
Date of Birth:
Allergies:
Has your kid attended the class last year?:	-- Please select -- Yes No
	Submit

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