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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 2022-23 Registration2 Children, WIS 2022-23 Registration3 Children, WIS 2022-23 Registration4 Children, WIS 2022-23 Registration5 Children, WIS 2022-23 RegistrationStudent # 1* First Last Student # 1 Date of Birth*Students must be 5 years old by Sep 1, 2022 to enroll. MM slash DD slash YYYY Student # 2* First Last Student # 2 Date of Birth*Students must be 5 years old by Sep 1, 2022, to enroll. MM slash DD slash YYYY Student # 3* First Last Date of Birth*Student must be 5 years old by Sep 1, 2022 to enroll. MM slash DD slash YYYY Student # 4* First Last Date of Birth*Students must be 5 years old by Sep 1, 2022 to enroll. MM slash DD slash YYYY Student # 5* First Last Date of Birth*Student must be 5 years old by Sep 1, 2022 to enroll. MM slash DD slash YYYY Part IV – Fees1 child – $300.00 2 children – $450.00 3 children – $600.00 4 children – $750.00 5 children – $900.00Total $0.00 Part V – PaymentCredit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name NumberNumberDate MM slash DD slash YYYY Δ
