NHIEC Boys and Girls Club Programs

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Email *

Child's Name: Last, First *

Date of Birth *

YYYY

Do you have Health Insurance

Yes

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Parent Name: Last, First *

Phone Number *

Female/Male *

Male

Female

Any known Allergies/Medicaons? Yes No *

Yes

If yes, Please list below

Medical Condition that we should be aware of? *

Yes

If yes, please list

I give permission to North Hudson Islamic Educational Center to obtain any medical care necessary for the welfare of my child/children through a qualified person, physician or hospital in case of any injury or sickness during school hours. I give permission for my child to participate in all school activities within the premises of North Hudson Islamic Educational Center or outside activities held in conjunction with the weekend Islamic school. I hereby waive all rights/claims against NHIEC, its management, weekend school teachers and volunteers. *

Yes

I allow NHIEC to use my child’s image and name for publications and media purposes *

Yes

Parent Signature *

Submit

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