TA Derry programs registration

1
Date* This field is required.
Date
Day
Month
Year
6
1
2
3
4
5
6
7
8
9
10
11
12
Hour
48
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
2
Select preferred course* This field is required.
Qur’an & Tajweed Program - 4 days ($135)
Junior Quran program - 2 days ($70)
Weekend Quran Program - 2 days ($70)
Private Quran: 2 days a week – 15 mins ($105)
Private Quran: 2 days a week – 30 mins ($180)
Private Quran: 1 day a week – 30 mins ($105)
Part-time Hifz 4 days ($195)
Adult Tajweed program ($115)
If you wish to register for multiple program, please list additional programs in comment section below.
3
Calculation
4
Please indicate whether you prefer your child to attend classes on-site or online?* This field is required.
In-Person Learning
Online Learning
5
Full Name* This field is required.
First Name
Last Name
6
Health Card #* This field is required.
7
Date of Birth* This field is required.
Date
Year
Month
Day
8
Current age of the enrolling student: age *
9
Gender* This field is required.
Male
Female
10
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Canada
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Home Phone
Area Code
Phone Number
12
Father* This field is required.
First Name
Last Name
13
Father Mobile* This field is required.
14
Father Email* This field is required.
15
Mother* This field is required.
First Name
Last Name
16
Mother Mobile* This field is required.
17
Mother Email* This field is required.
18
Please note: Emergency contact must be someone other than the parents.* This field is required.
Emergency Contact Person Name
Please Emergency Contact Phone
Relationship to register student
19
Have you previously enrolled in our program?* This field is required.
YESNO
20
Reason for joining and other comments (please use this section to request your preferred schedule)
21
Thank you for registering with Milton Quran Institute. Our admission dept. will be contacting you within 2 business days to discuss program details and schedule options. You may follow up with by phone 905-878-4300 or email reception@miltonquraninstitute.com

All Quran & Tajweed students will be assessed prior to starting their classes. Once an assessment is completed an associate will asssit in selecting the right program & schedule.

You will receive an automated email with a PAD form & institute policies, please submit the required form to admin@miltonquraninbstitute.com to complete your enrollement.

I hereby agree to abide by institute policies and release MQI and its employees from all claims of damage arising from any activity, accident or injury which is caused by or arises from the participation of the applicant(s) named herein, during any program or in any facility where the program is held.
22
Media Consent* This field is required.
Yes, I consent to my child being filmed, interviewed, audio recorded, videotaped, or photographed by school employees or agents during the academic school year, to be placed on the website and/or school social media.
No, I do NOT consent to my child being filmed, interviewed, audio recorded, videotaped, or photographed by school employees or agents during the academic school year, to be placed on the website and/or school social media.
23
Parent's SignatureI agree to the terms and conditions of Milton Quran Institute
Clear
24
Please proceed with the paymentMQI Registration
prevnext( X )
Description
CAD
+ OR enter a custom value
First Name
Last Name
Should be Empty: