WIS

Welcome to ICSGV Weekend Islamic School (WIS)

Registration Form - School Year 2024-2025
Weekend Islamic School - Islamic Center San Gabriel Valley
19164 E. Walnut Drive North, Rowland Heights, CA 91748

Date (mm/dd/yyyy) * ICSGV member * Required Fields

1. Student Information

	Name (First, MI, Last) *	Email	Reg. School Grade *
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

2. Parent Information

Mother's Name (First,MI,Last) *				Cell * -
Father's Name (First,MI,Last) *				Cell -

Address *		City*		Home*	-
State *		Zipcode *		Email *

All parents are encouraged to volunteer. It is recommended that parents volunteer one Sunday during the school year
Date - 1 (mm/dd/yyyy) Date - 2 (mm/dd/yyyy)

3. Registration Fee Tution fee 1st child: $475.00 per year; $50 discount for each suucessive child
ICSGV member gets $50.00 discount for 1st child; Payment plan available with $0.00 additional fee

4. Parent Permission and WaiverYour signature below will give permission for your child to participate in all school activities within the premises of Islamic Center of San Gabriel Valley (ICSGV) or outside activities held in conjunction with Weekend Islamic School. It will also waive all the claims against ICSGV for injury, accident, illness, or death during any school activities.
Signature of parent, guardian or student 18 years of age or older

5. Parent Consent for Medical TreatmentPlease list any allergy and medications used by your child on a regular basis

	Allergies	Medications
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Your signature below will grant consent to ICSGV to provide all Emergency dental or medical care prescribed by a duly licensed physician (MD), Osteopathy (DO), or Dentist (DDS) for the above named student. This care may be given under whatever condition necessary to preserve life, limb or well being of the student.

Signature of parent, guardian or student 18 years of age or older

6. Names of persons authorized to pickup child(ren) in Emergency

Name	Address	Phone	Driver Lic.