WIS Registration Weekend Islamic School Registration for WIS at HCIC Part I - Parent informationFather's name* First Last Father's Cell phone*Mother's name* First Last Mother's Cell phone*Home mailing address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone, if there is onePrimary Email address*This email will be used to send any WIS announcements such as Mid-term & Final exam, Quran competition, school closures, etc... Enter Email Confirm Email Part II - Emergency ContactEmergency Contact Name*Please list someone to call in case of an emergency if we are unable to reach either parents. First Last Emergency Contact PhonePlease put the best phone number for us to callEmergency contact relationship to child/children*GrandparentUncle/AuntCousinOtherDeclarationI hereby authorize the BIS-WIS to take my child/children to a licensed physician or medical center in the event of an emergency in which neither parents can be reached. Check here to accept Part III - Student informationHow many children are you registering?*1 Child, WIS 2019-20 Registration2 Children, WIS 2019-20 Registration3 Children, WIS 2019-20 Registration4 Children, WIS 2019-20 Registration5 Children, WIS 2019-20 RegistrationStudent # 1* First Last Student # 1 Date of Birth* Date Format: MM slash DD slash YYYY Student # 2* First Last Student # 2 Date of Birth* Date Format: MM slash DD slash YYYY Student # 3* First Last Date of Birth* Date Format: MM slash DD slash YYYY Student # 4* First Last Date of Birth* Date Format: MM slash DD slash YYYY Student # 5* First Last Date of Birth* Date Format: MM slash DD slash YYYY Declaration:*I hereby certify that I have received BIS-WIS parent - student handbook and will abide by the rules outlined in there. BIS-WIS is not responsible for injury on school premises or for children left at school before 10:00 am and after 1:15 pm. I accept this declaration Part IV - Fees1 child - $300.00 2 children - $400.00 3 children - $500.00 4 children - $600.00 5 children - $700.00Total $0.00 Part V - PaymentThis page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name
