Download form ICE_SCMS_Application_2018

Our Weekend School was established to provide an Islamic Education as well as an Islamic social outlet for our youth. As Allah tells us in the Quran, “save yourselves and your family”.
The school is in session every Sunday from 10am to 1pm. The school currently consists of approximately 60 students from various backgrounds and ethnicities. The age level ranges from 5 years old to 17 years old and consists of 4 levels.

The curriculum includes Wudu, Salah, Tawhid, Taqwa, Aqeedah, Hadith, and short surahs, Arabic and Islamic morals and manners are also covered. Books and other learning materials as well as a lunch is provided. The school does request a small tuition for operating cost.

The weekend school operates with a staff of volunteers who generously donate their time feesabillilaah. We also provide age appropriate trips and community service projects.

Islamic Center Of Ewing

Sister Clara Mohammed Weekend School (SCMWS)

685 Parkway Avenue Ewing, N.J. 08618
Tel.: (609) 406-9222 Fax (609) 406-1119
Date of Application*
MM slash DD slash YYYY
Information
- First name*
- Last name*
- Middle Ini.*
- Sex*
  - Male
  - Female
- Age*
- Date*
  MM slash DD slash YYYY
- Grade*
- Level*
Parent / Guardian #1
- First name*
- Last name*
- Middle Ini.*
- Home Telephone*
- Address*
- Cell #
- City*
- State*
- Zip Code*
- Relationship*
- Email Address*
Parent / Guardian #2
- First name*
- Last name*
- Middle Ini.*
- Home Telephone*
- Address*
- Cell #
- Email Address*
Please note this information will allow better placement for your child, if you need additional space, please attach an additional page with your explanation to the back of this application.
- 1. Does your child know Arabic?*
  - read
  - write
- 2. What Level:*
  - beginner
  - Intermediate
  - advance
- 3. Can your child perform the entire salat from start to finish?*
  - Yes
  - No
- 4. Is your child currently attending school?*
  - Yes
  - No
- 5. Have they ever attended Sis Clara Mohammed Weekend School?*
  - Yes
  - No
- 6. What level book did your child use? Level*
  - 1
  - 2
  - 3
  - 4
  - 5
- What languages does your child speak?*
- List the Surahs your child can recite by memory:*
Contact Emergency Information/Pick-Up Authorization Consent
List a person who is able to get to the Masjid within 30 minutes.
- First name*
- Last name*
- Middle Ini.*
- Relationship to child*
- Telephone*
- Work*
- Cell*
- First name*
- Last name*
- Middle Ini.*
- Relationship to child*
- Telephone*
- Work*
- Cell*
- First name*
- Last name*
- Middle Ini.*
- Relationship to child*
- Telephone*
- Work*
- Cell*
Child/ren may NOT be picked up by:
- First name*
- Last name*
- Middle Ini.*
- Relationship*
- First name*
- Last name*
- Middle Ini.*
- Relationship*
This is to be signed if your child/ren are of 12 years old or older. I request SCMWS to release my child at the end of the school day so that he/she may walk or bicycle home alone.
- Parent Signature*
- Date*
  MM slash DD slash YYYY
HEALTH RECORD
This confidential health record will only be used to ensure the safety of the children in this program.
- Student’s Name*
- Date of Birth*
  MM slash DD slash YYYY
1. Please provide your child’s medical history.
- - CONDITION
  - Asthma
  - Does your child use an inhaler?
  - Corrective Device (glasses, hearing aid etc.)
- - YES
  - Asthma
    - Yes
  - Does your child use an inhaler?
    - Yes
  - Corrective Device (glasses, hearing aid etc.)
    - Yes
- - No
  - Asthma
    - No
  - Does your child use an inhaler?
    - No
  - Corrective Device (glasses, hearing aid etc.)
    - No
- - ALLERGY
  - Penicillin
  - Insect Sting
  - Food
  - Plants
  - Hay Fever
  - Topical Ointments
  - Other
- - YES
  - Penicillin
    - Yes
  - Insect Sting
    - Yes
  - Food
    - Yes
  - Plants
    - Yes
  - Hay Fever
    - Yes
  - Topical Ointments
    - Yes
  - Other
    - Yes
- - NO
  - Penicillin
    - No
  - Insect Sting
    - No
  - Food
    - No
  - Plants
    - No
  - Hay Fever
    - No
  - Topical Ointments
    - No
  - Other
    - No
If ‘yes’ please specify allergy & describe
- 3.Special situations or needs that program staff should be award of:
- Special situations or needs that program staff should be award of:
  - Child has physical disabilities
  - Child has behavioral/emotional problems
  - Other (describe)
- Health/Insurance Information:
- Student’s Doctor:
- Doctor’s Phone:
- Address
- Insurance Company:
- Policy Holder’s ID#.
- Allergies
- Last Tentanus:
- Medications being taken:
- Religious reference: (optional)
- Additional Comments:
- If my child requires emergency medical care and I cannot be reached, I give my consent to the above after-school program to obtain the necessary medical care for my child. I agree to pay all of the costs associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after care is provided.
- 4. SPECIAL HEALTH CARE NEEDS Does your child have special health care needs that require treatment and/or medication
  - YES
  - NO
- If yes, describe below. If your child requires treatment and/or medication during after-school hours, complete the Health Care Plan for Child with Special health Care Needs form.
- 5. MEDICATION Does your child take medication for any condition or illness?
  - YES
  - NO
- If yes, describe below. If your child requires medication during after-school hours, complete the Medication Consent Form
- 6. ACTIVITIES YOUR CHILD CANNOT PARTICIPANT IN
- 7. ACTIVITIES TO BE ENCOURAGED:
- My child may participate in all program activities, except those noted in number 8 above. I understand that this consent will be in effect as of the date of my signing this form and will continue as long as long as my child is enrolled in this after-school program.
- Parent/Guardian Signature
- Date
  MM slash DD slash YYYY
EMERGENCY MEDICAL CARE
- Date
  MM slash DD slash YYYY
- Student’s Name
- Date of Birth
  MM slash DD slash YYYY
- If my child requires emergency medical care and I cannot be reached, I give my consent to the above SCMWS program to obtain the necessary medical care for my child. I agree to pay all of the costs associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after care is provided. The following emergency medical care, my child may be released to the following people.
- Name
- Relationship to Child
- Home Phone
- Work Phone
- Cell Phone
- Name
- Relationship to Child
- Home Phone
- Work Phone
- Cell Phone
- Name
- Relationship to Child
- Home Phone
- Work Phone
- Cell Phone
- Health/Insurance Information:
- Student’s Doctor:
- Doctor’s Phone:
- Address
- Insurance Company:
- Policy Holder’s ID#.
- Medications being taken:
- Religious reference: (optional)
- Additional Comments:
- I understand that this consent will be in effect as of the date of my signing this form and will continue as long as long as my child is enrolled in the SCMWS.
- Parents/Guardian Signature
- Date
  MM slash DD slash YYYY
- WAIVERS & RELEASES
  PHOTO / VIDEO CONSENT
- - I -
  - print parents name clearly
  - certify that I am the parent or legal guardian of -
  - print child’s name clearly
  - whose date of birth is
  - month / day/ year
    MM slash DD slash YYYY
- I understand that SCMWS features special events both in school and away from school. Media representative, newspaper and television reporters, photographers, and SCMW personnel may be present at these special events to record them. In some cases they may interview and/or photograph children who participate in these events. These photographs, videos, and interviews will only be used to promote SCMWS. I hereby give permission for my child to be photographed or otherwise recorded during SCMWS events and activities, and for any all such photographs to be displayed, In addition to Any information we collect will be used only for SCMWS and will not be made public. We will not use your child/ren’s name or your name on any report. Participating in the evaluation will not affect your child/ren in school, in the SCMWS, or in any other way.
- Signature of parent or guardian name
- Date
  MM slash DD slash YYYY
- If you do not wish for your child to participate in the activities described above, please review this section of this form. I DO NOT give permission for my child to be photographed or otherwise recorded during SCMWS events and activities. As a result, my child may not be able to participate in these events and activities.
- Signature of parent or guardian name
- Date
  MM slash DD slash YYYY
- PARENT RELEASE
  I the Undersign, hereby release, absolve, indemnify and hold harmless the Islamic Center of Ewing Sister Clara Mohammed Weekend School, their leader and anyone appointed by the (ICE SCMWS) from all liability from any injury or damage sustained while participating in the SCMWS. In addition, I am not aware of any reason that my child would not be able to participate in any activities on the Masjid grounds or field trips they may partake in.
- Signature of parent or guardian name
- Date
  MM slash DD slash YYYY
- CODE OF CONDUCT PARENT AGREEMENT
  I have received and reviewed a copy of the Family-Student Handbook. I have thoroughly read and agree to the terms of the policies in the Handbook. I am fully committed to the responsibilities fees and expensive of being a parent of a child who attends the SCMWS regularly.
- Signature of parent or guardian name
- Date
  MM slash DD slash YYYY
- Islamic Center Of Ewing Sister Clara Mohammed Weekend School (SCMWS) THIS PAGE IS FOR OFFICIAL USE ONLY DO NOT WRITE ON THIS PAGE
- AMOUNT PAID:
- $
- FORM OF PAYMENT:
- CASH
  - CASH
  - CREDIT CARD
  - CHECK
- #
- Check here if the parent would like to apply for a Fee Waiver.
  - Check here if the parent would like to apply for a Fee Waiver.
- Comments:

Connect with us

685 Parkway Ave, Ewing, NJ 08626
info@islamicenterofewing.com
FAX : 609 406 1119

or Call (609) 406-9222

Islamic Center Of Ewing

Sister Clara Mohammed Weekend School (SCMWS)

Information

Parent / Guardian #1

Parent / Guardian #2

HEALTH RECORD

EMERGENCY MEDICAL CARE

WAIVERS & RELEASES

PARENT RELEASE

CODE OF CONDUCT PARENT AGREEMENT

Islamic Center Of Ewing Sister Clara Mohammed Weekend School (SCMWS) THIS PAGE IS FOR OFFICIAL USE ONLY DO NOT WRITE ON THIS PAGE

Connect with us