Masjid Al-Mumin

Weekend School
Application

Please complete all sections of this application. Once submitted, our team will review it and contact you regarding next steps, in sha' Allah.

Student Information

Tell us about the student applying.

First Name *

Last Name *

Date of Birth *

Grade Level *

Gender

Primary contact for this student.

Full Name *

Relationship *

Email Address *

Phone Number *

Home Address *

Someone we can reach in case of emergency, other than the parent/guardian above.

Full Name *

Relationship *

Phone Number *

Leave blank if not applicable.

Allergies

Current Medications

Additional Medical Notes

By submitting this application, I confirm that:

I have read and agree to the above terms. *

Electronic Signature (type your full name) *