Islamic Society of Pinellas County
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ISPC Summer School Application Form
Fri, 01/25/2013 - 11:59pm — admin
Please fill out the form below.
First Name:
*
Last Name:
*
Date Of Birth:
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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31
Year
1961
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2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Age:
*
Gender:
*
Male
Female
Fathers Name:
*
Cell Phone:
*
Fathers Email:
*
Work Phone:
Mothers Name:
*
Cell Phone:
*
Home Phone:
Mothers Email:
*
Address:
*
City:
*
Zip Code:
*
Emergency Contact:
Name of Emergency Contact:
Emergency Contact Cell Phone:
*
Address:
*
City:
*
Zip Code:
*
Emergency Contact email:
Relationship:
*
Food Allergies?:
Other Allergies including Medical Allregies?:
Other Information Essential for The School to Attend to the Student's needs:
I give permission to take picture of my child for class projects and/or masjid website:
*
Yes
No
I authorize sunday school teachers/administrators/safety officers at Masjid Ebad Al Rahman to seek any and all emergency health :
*
Yes
No
I am also willing to support the school either by committing time or financial support:
*
Yes
No
I commit to dropping my child off and pick up from the school on time in Shaa Allah:
*
Yes
I agree to terms and conditions of ISPC School:
*
Agree
Re-Occuring Donation
How many times would you like this to recur? (including this payment)
Never End
2
3
4
5
6
7
8
9
10
11
12
When would you like this to Repeat?
Monthly
Yearly
Daily
Enter Your Donation Amount(USD)
Donation Type (Zakat, Sadaqah)