Evening School Registration Evening School Registration Please Enter Your Child's Information, and click on the (+) icon on the far right to add additional children to this list.*If you have more than 1 child to register, please click on the (+) icon next to the Age field on the far right. Child's First NameLast NameGenderDate of BirthAge Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address*Please enter an email address you check frequently. Father's Name, Contact Number (cell, home, work) Mother's Name, Contact Number (cell, home, work) Guardian's Name, Contact Number (cell, home, work)This field is optional. Please enter Guardian's relationship to child if applicable. Please enter the number you would primarily like to be contacted(if needed):* Do you give Masjid al-Huda permission to photograph/videotape your children for the purpose of marketing our programs? Yes I Do! No I Do Not. Medical Information (Important)In the event of injury or illness, if your family physician is not available or is not located in the immediate vicinity and we are unable to contact a parent, does the staff have your permission to seek medical attention from the nearest licensed physician and/or hospital?* Yes, please seek nearest medical attention No, contact me first before taking any action My child is covered by medical insurance:*If you're registering multiple children, and some of them are NOT covered by medical insurance, please insert their names in the box below. Yes No Please list any known allergies (food, drugs, pollen, bees, etc)If you're registering multiple children, please let us know the individual allergies of each child.Please list any medical conditions/disabilities: (if applicable)If you're registering multiple children, please let us know the individual conditions of each child.Emergency Contact Information (if other than parent/guardian)Contact’s name, number (cell, work, home), relation to childAny Additional Information You Would Like to Provide?If there's anything else we need to know about your child, please type it here. Your information will be kept private & confidential.AcknowledgementBy signing below, I agree to abide by the rules of Guidance Academy and I understand that if I wish to later cancel our application, there will be a 50% cancellation fee applied.Electronic Signature (Please Type First & Last Name)*Please type your first & last name, which will serve as an electronic signature.