2022/2023 IQRA Evening School Registration

Medical Information
Health Card Number*
Allergies
Additional Medical Notes
Terms of Agreement
In the event of an emergency, if I cannot be reached, I authorize the calling of a doctor/Certified Emergency Personnel and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that although the Weekend School will be staffed by mature and responsible adults who will do their best to ensure the well-being of my child/children, I shall not find the Weekend School, Abu Huraira, or their staff liable for any injury or loss of property.*

I agreeI disagree

Payment Information
(Tuition is $65 per child per month. Only payment option is monthly bank withdrawals on the 21st of every month. There is a $25 NSF Charge. All requests to stop automatic withdrawals must be given ONE (1) month prior. No Electronic Funds Transfer (EFT) cancellations last THREE (3) months of school year.)
Name of Account Holder*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Account Number*
Institution Number*
Transit Number*

Photography & Media Release
I hereby give Abu Huraira Center consent to use and reproduce my child(ren)'s name/image for promotional, educational, and fundraising purposes related to Abu Huraira Center.
I understand and agree to the above statement.*

YesNo
Parent Signature*

Clear
Date Signed*

MonthDayYear
Date
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General Information