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ADD YOUR ORGANIZATION/CENTER/SCHOOL

The purpose of this questionnaire is to gather information on Masjids, Organizations, Schools, etc. that are serving the Muslims. This is a long form. You don't have to fill out all the fields. Please provide us with as much information as possible.

1.1 About the Organization

Organization's Name:
Nature of Organization:		Masjid/Islamic Center Organizations School Relief Youth Social Services Welfare Ethnic Other:
Street Address:		City:
State:		Zip Code:
Phone number: 123-456-7890		Fax number: 123-456-7890
E-mail address:		Website: http://

1.2 Leader's Name

Title	First Name	Middle Name	Last Name

Street Address:		City:
State:		Zip Code:
Phone Day: 123-456-7890		Phone Eve.: 123-456-7890
Fax Number 123-456-7890		E-mail Address:

1.3 Attendance

How many members do you have?

How many people attend Juma?

1.4 What ethnic groups attend your programs generally? (Check all that applies)

African Albanian Arab Bangali Bosnian
Ethiopian French Guyanese Indian Pakistani
Somali Spanish Srilankan Turkish
Other

2.1 Please check all of the following activities that apply to your Organization:

5 daily prayers Taraweeh Full-time school Week-end school Interfaith

Juma:

Khutba Time: hr: min: PM.
Main Khutba Language:
Women's space? Yes No

Annual Dinner Zakah Women's Program Youth Program Sports
Picnic Funds for Relief National Day Immigration Help
Job Help Free Health Drive Family Counseling Arbitration
Media Relations Legal Advocacy Youth Center Recreational
Social Services: Phone #
Political Activities: Phone #
Funeral Preparation: Phone #
Marriage: Phone #
Matrimonial: Phone #

Non-English Program Languages:
(click all that applies)

Arabic Albanian Bangla Bosnian
French Somali Sinhali Tamil
Turkish Urdu
Other

3.1 If you have a Dawa committee, please fill out the following items about the head:

First Name	Middle Name	Last Name

Street Address:		City:
State:		Zip Code:
Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:

3.2 If you have a Women's committee, please fill out the following items about the head:

First Name	Middle Name	Last Name

Street Address:		City:
State:		Zip Code:
Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:

3.3 If you have a Youth committee, please fill out the following items about the head:

First Name	Middle Name	Last Name

Street Address:		City:
State:		Zip Code:
Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:

4.1 Quran class/dars/circle ( Yes No )

Days:	Sat Sun Mon Tues Wed Thurs Fri	Time:	hr: min: AM PM
Suitability: Men Women Youth Non-Muslim New Muslim
Language:

4.2 Arabic class ( Yes No )

Days:	Sat Sun Mon Tues Wed Thurs Fri	Time:	hr: min: AM PM
Suitability: Men Women Youth Non-Muslim New Muslim
Language:

4.3 Weekend School ( Yes No )

Principal's First Name	Middle Name	Last Name

Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:

Street Address:		City:
State:		Zip Code:

Days:	Sat Sun	Time: hr: min: AM PM
Age Groups:	boys girls	Registration Date: (mm/dd/yy)
School Session Begins: (mm/dd/yy)		School Session Ends: (mm/dd/yy)
Comments:

4.4 Evening School ( Yes No )

Principal's First Name	Middle Name	Last Name

Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:

Street Address:		City:
State:		Zip Code:

Days:	Mon Tues Wed Thurs Fri Sat Sun	Time: hr: min: AM PM
Age Groups:	boys girls	Registration Date: (mm/dd/yy)
School Session Begins: (mm/dd/yy)		School Session Ends: (mm/dd/yy)
Comments:

4.5 Full time School ( Yes No )

Principal's First Name	Middle Name	Last Name

Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:		URL: http://

Street Address:		City:
State:		Zip Code:

Grades:

JKG KG 1
2 3 4 5
6 7 8 9
10 11 12
OAC

boys girls

Registration Date: (mm/dd/yy)

School Session Begins: (mm/dd/yy)

School Session Ends: (mm/dd/yy)

Comments:

4.6 New Muslim Class ( Yes No )

Contact Person's First Name	Middle Name	Last Name

Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:

Days:	Sat Sun Mon Tues Wed Thurs Fri	Time: hr: min: AM PM
Suitability: Men Women Youth Non-Muslim

4.7 Library ( Yes No )

Open Days:

Sat Sun Mon
Tues Wed Thurs
Fri

Time: hr: min: AM PM

Books in:

Arabic Albanian Bangla Bosnian Somali
Sinhali Tamil Turkish Urdu
Children's
Other:

4.8 Bookstore ( Yes No )

Open Days:

Sat Sun Mon
Tues Wed Thurs
Fri

Time: hr: min: AM PM

4.9 Social Programs ( Yes No )

Title

Days:	Sat Sun Mon Tues Wed Thurs Fri	Time: hr: min: AM PM
Suitability: Men Women Youth Non-Muslim New Muslim

Describe:

4.10 Additional Weekly Programs ( Yes No )

Please write three of your weekly programs not covered above. Don't forget to write description, target audience, where and when in each.
Weekly Progam 1
Weekly Progam 2
Weekly Progam 3

4.11 Monthly Programs ( Yes No )

Please write three of your monthly programs not covered above. Don't forget to write description, target audience, where and when in each.
Monthly Progam 1
Monthly Progam 2
Monthly Progam 3

4.12 Any additional activity or information which is not covered above: (please include what, where, when, and target audience)

5.1 Provide information on one of your community activist whose name have not appeared in the form.

First Name	Middle Name	Last Name

Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:

6.1 About the Information Provider (This information will not be published. This will be used only to verify and update information)

First Name	Middle Name	Last Name

Phone Number: 123-456-7890		Fax Number: 123-456-7890
E-mail Address:
Comments/Suggestions: