Kids Registration Form

Child

First

Middle

Last

Gender MaleFemale

School Name

Grade

Date of Birth

Age

Street Address

Town/City

State

Zip Code

Child's Home Phone

Parent/Guardian - Contact Information
Parent/Guardian #1

First

Last

Ms. Mrs. Mr. Other

Street Address

Town/City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Fax

Email

Occupation

Employer

Parent/Guardian - Contact Information
Parent/Guardian #2

First

Last

Ms. Mrs. Mr. Other

Street Address

Town/City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Fax

Email

Occupation

Employer

Child lives with

Emergency Contact Information – Alternate Pickup/Release
Emergency Contact #1

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Email

Relation to Child

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Medical Problem

Required Treatment

Is your child allergic to any type of food or medication?
NoYes

If Yes, Explain

In case of medical emergency contact:

Contact# 1

Name

Phone#

Relation to Child

Contact# 2

Name

Phone#

Relation to Child

Contact# 3

Name

Phone#

Relation to Child

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services, in the event my child is injured or becomes ill.

I understand that Niagara Islamic Community Center will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility of parent/guardian.

Terms of Agreement

Photo Release

I hereby give permission for my child to be photographed during NICC term attendance. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of The Niagara Islamic Community center.