PMC Girls Activity - Islamic Center of Peoria

Child Information

Name *

First, Middle, Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information *

Father's Information
Mother's Information
Both Parents Information

Father's Information

Name *

Email *

Phone *

Mother's Information

Name *

Email *

Phone *

Best Method of Contact *

Father’s cell phone
Mother’s cell phone

Consent *

I Agree

I, apply for Peoria Muslim Club Soccer Club membership for my children, and agree to comply with the bylaws and policies of Peoria Muslim Club and Islamic Center of Peoria.

I, also, agree on behalf of the names above to release and hold harmless Peoria Muslim Club, Islamic Center of Peoria, their officers, directors, employees, and agents, and each of them, from any claims, demands, or actions we may have against them because of this application

Child Information

Father's Information

Mother's Information

Contact Info

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