WIS Registration Weekend Islamic School – Registration 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/AuntCousinOtherDeclaration*I 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?*Select below1 Child, WIS Registration2 Children, WIS Registration3 Children, WIS Registration4 Children, WIS Registration5 Children, WIS RegistrationStudent # 1* First Last Student # 1 Date of Birth*Students must be 5 years old by Sep 1, 2024 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, 2024, to enroll. MM slash DD slash YYYY Student # 3* First Last Date of Birth*Student must be 5 years old by Sep 1, 2024 to enroll. MM slash DD slash YYYY Student # 4* First Last Date of Birth*Students must be 5 years old by Sep 1, 2024 to enroll. MM slash DD slash YYYY Student # 5* First Last Date of Birth*Student must be 5 years old by Sep 1, 2024 to enroll. MM slash DD slash YYYY Part IV – Fees1 child – $300.00 2 children – $500.00 3 children – $700.00 4 children – $900.00 5 children – $1100.00Please consider paying security charges ($50 per child)* Yes, I would like to pay for security No, I do not want to pay Security Charges (1 Child) Price: Security Charges (2 Children) Price: Security Charges (3 Children) Price: Security Charges (4 Children) Price: Security Charges (5 Children) Price: Total $ 0.00 Part V – PaymentCredit Card Card Details Cardholder Name Δ
