Student’s Name
Parent/Guardian Name
Date of Birth
Gender
Home phone number
Cell
Email Address
Home Address
Emergency contact Person/ Phone
Health Card number
Allergies
Name
Email Address
Current Address
Ph (H)
Ph (C)
Fax
Ph (w)
City
Prov
Postal Code
Current Profession
Specialization

SPOUSE INFORMATION (If Apply For Family Membership)

Name
Email Address
Ph (W)
Ph (C)
Current Profession
Specialization
Name
Email
Phone

DECLARATIONS (Circle appropriate response)

I am a Muslim over the age of 18
YesNo
I am Permanent resident OR Citizen of Canada(Will provide proof upon request)
YesNo
I am living in Saskatchewan for at least six months(Will provide proof upon request)
YesNo
I will abide by the constitution and By-Laws of Rahmah Centre Inc.
YesNo
I am not a member of any other Islamic Organization in Saskatchewan
YesNo
Date