Ihsan Academy General Program at ICPC-Paterson (Boys & Girls 5-12 years old) Summer 2025

Page 1

Form instructions:
Kindly use a Google browser or make sure your Safari browser is cleared.

Please use the form below to register your students. For each additional student, please use the 'Add another student' button at the end of the student section.
For additional Emergency Contacts, please use the 'Add another Emergency Contact' button.

For any questions, please contact ihsanacademy@icpcnj.org

Guardian Information

First Name

Last Name

Phone

Confirm Email

Gender

Guardian Address

Address Line 1

Address Line 2

City

Country

State

Postal Code

Student Information

First Name

Last Name

Gender

Birthdate

Same address as guardian?

YesNo

Address Line 1

Address Line 2

City

Country

State

Postal Code

Health & Safety

Does your child have any allergies?

Yes

Please list them below, including severity and Epipen requirements:

Does your child have any dietary restrictions?

Yes

Please list them below:

Does your child have an IEP (Individualized Education Plan)?

Yes

What is your t-shirt size?

Cost

Count

Emergency Contacts

Emergency Contact Details

First Name

Last Name

Phone

Relationship

Attendee Type

Page 2

Discount

Review

Students selected for a subtotal total of:

Disclaimer:
There will be a 5% sibling discount, which will be issued as a refund at a later date. Please note that this refund will be processed within a week of the initial transaction.

Payment Information

Name on Card

Card Number

Code

Billing Email

In order to prevent duplicate charges, please do not use your browser's back button or press submit more than once.