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Islamic Society of Augusta Summer Camp 2010 Registration Form

Islamic Society of Augusta Summer Camp 2010 Registration Form

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Published by Ayman Hossam Fadel

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Categories:Types, Brochures
Published by: Ayman Hossam Fadel on May 17, 2010
Copyright:Attribution Non-commercial

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05/17/2010

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ISLAMIC SOCIETY of AUGUSTASummer Camp 2010June 1 – July 31
Enrollment Application# _______________ Date _______ / ________/________
Student’s Name ________________________________________Age ________ Date of birth ____/____/____Gender of child: Male _____ Female_____Address ______________________________________________________City __________________________State_____ Zip __________Person Responsible for Payment __________________________________Mother’s Name ________________________________________________Mother’s Contact Number _______________________________________Father’s Name _________________________________________________Father’s Contact Number ________________________________________Name and phone number of at least two other persons to contact if parents cannot be reachedName _________________________________________ Phone__________________________Name _________________________________________ Phone__________________________Person who may pick up your child other than parentsName___________________________________Relationship___________________Phone________________Name___________________________________Relationship___________________Phone________________Name___________________________________Relationship___________________Phone________________Please list names and ages of other children in the family__________________________________________________________________________
Special Needs:
Check all meals & snacks you would like for your child: AM Snack____ Lunch_____ PM Snack____Allergies or Food Restrictions? If yes, please list:_________________________________________________________________________________Prescribed Medications? If yes, please describe:_________________________________________________________________________________Mobility Limitations? If yes, please describe:_________________________________________________________________________________Other physical or mental needs requiring staff attention: If yes, please describe:_________________________________________________________________________________

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