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Abu Hanifa Institute

Youth Mentoring Enrolment

Grounding the next generation in knowledge, character and connection. Complete the form below to register your child for the Wednesday and Thursday mentoring programme.

Sessions Wednesday & Thursday Location Berala Community Centre Enquiries 0497 792 296

Wed/Thur Mentoring (Extended)

Youth Mentoring Enrolment

Parent Details

First Name

Last Name

Phone

Email

Date of Birth

Gender

Male

Female

Address

Address Line 1

Address Line 2

City

State

Post Code

Country

Register Child (1)

First Name

Last Name

Gender

Male

Female

Date of Birth

Has your child ever been diagnosed with a medical condition. This includes a learning disorder, or any other behavioural or developmental condition? Note: this does "not" exclude your child.

Yes

No

Is your child currently taking any medication?

Yes

No

Does your child have any food allergies?

Yes

No

Register Child (2)

Do you want to register a 2nd child?

Yes

No

First Name

Last Name

Gender

Male

Female

Date of Birth

Has your child ever been diagnosed with ADHD, autism, a learning disorder, or any other behavioural or developmental condition?

Yes

No

Is your child currently taking any medication?

Yes

No

Does your child have any food allergies?

Yes

No

Register Child (3)

Do you want to register a 3rd child?

Yes

No

First Name

Last Name

Gender

Male

Female

Date of Birth

Has your child ever been diagnosed with ADHD, autism, a learning disorder, or any other behavioural or developmental condition?

Yes

No

Is your child currently taking any medication?

Yes

No

Does your child have any food allergies?

Yes

No

Emergency Contact

First Name

Last Name

Phone/Mobile

Photograph Consent: I consent to my child being photographed during activities.

Yes

No

Yes, but release with consent

Sports: my child is allowed to participate in mild sport (e.g., Oztag)

Yes

No

For more information, text 0497 792 296 or 0415 444 251.

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Youth mentoring
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Contacts below

Address 23 York St Berala
Phone 0407 480 097
Email admin@AbuHanifaInstitute.com

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