Maktub – AIM-Masjid Noor

New Student Application Form

Student Name *

First

Last

Gender *

Age *

Date of Birth *

Home Address *

1st Guardian's Name, Phone Number, and email Address *

2nd Guardian's Name, Phone Number, and email Address

Emergency Contact Name and Phone Number *

Comments

Liability Waiver *

AS THE PARENT/LEGAL GUARDIAN OF AFOREMENTIONED STUDENT, I HEREBY AGREE TO RELEASE, DEFEND, INDEMNIFY HOLD HARMLESS, AND FOREVER DISCHARGE THE ADMINISTRATORS OF THE MASJID NOOR, ITS ADMINISTRATORS, TRUSTEES, OFFICERS, FACULTY, STAFF, AGENTS AND OTHER REPRESENTATIVES (COLLECTIVELY, “THE MASJID”), ON BEHALF OF MYSELF, MY CHILDREN, MY PARENTS, MY HEIRS, ASSIGNS, PERSONAL REPRESENTATIVES AND ESTATE FROM ANY AND ALL CLAIMS, DEMANDS OR CAUSES OF ACTION WHICH IN ANY WAY RELATE TO OR ARISE OUT OF MY CHILD'S PARTICIPATION IN THE PROGRAM OR HIS/HER USE OF THE MASJID’S EQUIPMENT OR FACILITIES, REGARDLESS OF WHETHER CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY NEGLIGENT ACTS OR OMISSIONS OF THE MASJID.

eSignature of Parent/Guardian (Full Name and Date) *

Assalamualiakum,

Please setup an automatic payment option for $80 per child per month.

$80 monthly fee for one student

$160 monthly fee for two students

$240 monthly fee for three students

$320 monthly fee for four students

Jazakallah Khair,

Masjid Noor Maktab Committee

8608 Pohick Road, Springfield, VA, 22153