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Muslim Youth of OPPC Membership Form
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Guardian Information
If registering yourself, put your own information
Last Name
*
Your answer
First Name
*
Your answer
Cell Phone
*
Your answer
Current Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zipcode
*
Your answer
Name of Spouse
Your answer
Cell Number of Spouse
Your answer
Children's Information
If registering yourself, skip.
Name of Child 1
Your answer
Sex
Male
Female
Clear selection
Birthday of Child 1
MM
/
DD
/
YYYY
Phone Number
If they have their own phone
Your answer
Name of Child 2
Your answer
Sex
Male
Female
Clear selection
Birthday of Child 2
MM
/
DD
/
YYYY
Phone Number
If they have their own phone
Your answer
Name of Child 3
Your answer
Sex
Male
Female
Clear selection
Birthday of Child 3
MM
/
DD
/
YYYY
Phone Number
If they have their own phone
Your answer
Comments and/or additional children
If additional children add name and birthdate
Your answer
Emergency Contact Info
Name of Emergency Contact
Your answer
Phone Number of Emergency Contact
Your answer
Relationship to Children
Your answer
Misc.
How often do you/your kids go to the youth programs?
*
More than once a week
Once a week
Once in a while
I/They don't attend any programs
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