SILC Registration Form

School Year

Cass Type* Cass Type* Islamic Studies Urdu Classes Fiqh Classes Qira'at o nasheed

Class Group* Class Group*Level kg (Age 4)Level 1 (Age 5)Level 2 (Age 6)Level 3 & 4Level 5 & 6Level 7 & 8Level 9 & 10Level 11 & 12Level 13 (Age 17+

STUDENT INFORMATION

First Name*

Last Name*

Address

City

State/Provision/State

Country

Postal Code

Date of Birth*

Age

Gender

PARENT/GUARDIAN INFORMATION

Father Name*

Mother Name*

Father Phone*

Mother Phone

Father Email*

Mother Email

Father Occupation

Mother Occupation

Home Tel

Home Tel

EMERGENCY CONTACT FORM

Emergency #1 Name

Emergency #2 Name

Emergency #1 Relation

Emergency #2 Relation

Emergency #1 Phone

Emergency #2 Phone

STUDENT MEDICAL / HEALTH INFORMATION

Family Physician Name

Physician Phone #

Physician Address

Health Card Number ( OHIP )

Medical Condition / Allergies ( Please List )

Is the Student Taking Medicines On Daily Basis ? Is the Student Taking Medicines On Daily Basis ? Yes No

If Yes, Please Indicate :

Please Indicate Any Medical Conditions we should be aware of ( If Any )

PARENTAL CONSENT FOR EMERGENCIES : In the event of any injury requiring any medical attention, i hearby grant permission to SILC to share any information listed within this form with the supervising teacher, staff or medical personnel in order to attend to my child during school of hours. i understand the every effort will be made to contact me, however, if the injury warrants emergency medical attention and i am unreachable, i grant permission to SILC school for necessary medical treatment to be given, including permission to transport my child/children to nearest medical facility.

Parent / Guardian Signature :

Electronic Signature Electronic Signature Electronic Signature

EMAIL AUTHORIZATION : Please Add My Email Address To The School's Mail List To Recieve Important School Announcment & Updates

Email authorization Email authorization Yes No