SAMY Program - Registration

Student

First Name: *

Last Name: *

Home Phone: *

ex: 555-555-1234

Cell Phone: *

ex: 555-555-1234

Email: *

Address Line 1: *

Address Line 2:

City: *

State: *

Zip Code: *

Names and Birthdates of Siblings:

Please e-mail me about program updates and upcoming youth group events: *

Yes

Parents

Father or Legal Guardian

First Name: *

Last Name: *

Mother or Legal Guardian

First Name: *

Last Name: *

Home Phone: *

ex: 555-555-1234

Cell Phone: *

ex: 555-555-1234

Email: *

Please e-mail me about program updates and upcoming youth group events: *

Yes

Are you willing to assist in carpooling arrangements for SAMY activities?: *

Zip Code / Area of residence:

How many passengers can your vehicle seat:

How far are you willing to travel: miles

Terms and Conditions: *

I agree to the following terms

By submitting this form, I understand that being in SAMY is a privilege, not a right. I agree to follow instructions and respect the SAMY leadership. I understand that if I do not comply, I may be removed from the class and/or program entirely.
I also understand that the Sacramento Area League of Associated Muslims (SALAM) are not responsible for any injuries, harm, or loss of property as a result of my child’s participation in this program. I also consent to and permit emergency medical treatment in the event of injury or illness.

Emergency Contacts

Emergency Contact 1

First Name: *

Last Name: *

Relation: *

Home Phone: *

ex: 555-555-1234

Cell Phone: *

ex: 555-555-1234

Emergency Contact 2

First Name: *

Last Name: *

Relation: *

Home Phone: *

ex: 555-555-1234

Cell Phone: *

ex: 555-555-1234

Medical Information

Doctor: *

Office Phone: *

ex: 555-555-1234

Address Line 1: *

Address Line 2:

City: *

State: *

Zip Code: *

Medical Insurance Number: *

Student's Personal ID Number: *

Allergies: *

Any Health Issues?: *

Medication: *

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SAMY Program - Registration