Online Registration

Child Name *

First

Last

Age *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

School Name *

Grade *

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Home Phone

Work Phone

Cell Phone *

Parent/Guardian #2 Name

First

Last

Email

Home Phone

Work Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Alternative person to pick up scout(s) Name

First

Last

Home Phone

Work Phone

Cell Phone

Alimah Scouts Leadership Program

Alimah Youth Leadership Program The Alimah Youth Leadership Program will not accept financial responsibility as a result of medical treatment provided for any of its members. In the event that medical treatment is provided, AYLP staff will seek qualified medical assistance. I have read and understood the above statement and relinquish The Alimah Youth Leadership Program &Masjidullah from any financial responsibility as a result of necessary medical treatment to my child. I’m requesting that my child be allowed to participate in the above registration process

Medical Information

Does your child(ren) have any medical concerns, special needs, and/or behavior concerns i.e. (allergies, learning disabilities, ADHD). Is your child(ren) taking any medications? If so what medications and how often. If any discrepancies develop child(ren) will be dismissed from the program. *

No
Yes

If yes, please list

Name of Parent/Guardian filling out regisration form *

First

Last

Date / Time *

Alimah Scouts Leadership Program

Medical Information

ADDRESS