Registeration Form

Registeration Form
4992 W. Irlo Bronson Memorial Hwy; Kissimmee, FL 34746

Phone: (407) 910-1459 Email: admissions@izzadeenacademy.org Website: www.izzadeenacademy.org
New Student Enrollment Form 2023 – 2024
New Student Enrollment Form 2023 – 2024
New Student Enrollment Form 2023 – 2024
Last Name First Name Grade
Application Date

MonthDayYear
Date
Please use the checklist below as a guide and submit all required documents along with the registration fee to be considered for enrollment. Application submitted without applicable fees and required documents will not be

accepted. Both parents (if applicable) or legal guardian are required to sign the application form. Students will

not be allowed to attend the first day of class until all documents/forms are submitted and confirmation email is sent out.
Grade 1 - 9
Date
2. Copy of Birth Certificate

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3. Valid Proof of Physical DH 3040 (or equivalent school entry health exam

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4. Valid Florida Immunization Certificate DH 680

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5. Copy of the last 2 years Report Cards of (last year for 1 grade)

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6. Copy of Standardized Test Results grade 1 - 9

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7. Copy of Detailed Student Profile/ Discipline Record (required) grade 1-9

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8. Proof of Guardianship (if applicable)

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9. Withdrawal Letter from previous school grade 1 - 9

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*Kindergarten (KG) applicant must be 5 years old by or on September 1. A Kindergarten Immunization Record th must be provided and meets Part A DOE Code 1 requirement. For 7th through 9 Grade, student must complete DTaP Immunization Record, which must meet Part A DOE Code 8 requirement.
STEP UP FOR STUDENTS (SUFS) SCHOLARSHIP INFORMATION
Access www.stepupforstudents.org beginning March 1, 2020 for new enrollment information and income guidelines.
Your child(ren)’s enrollment at IZZADEEN ACADEMY will not be confirmed until the SUFS Award Letter is submitted showing that your child has been approved for scholarship and for the amount allocated by SUFS.
Primary Guardian
Date

MonthDayYear
Date
Secondary Guardian
Date

MonthDayYear
Date
Registration Administrator
Date

MonthDayYear
Date
Principal
Date

MonthDayYear
Date
Izzadeen Academy
4992 W. Irlo Bronson Memorial Hwy; Kissimmee, FL 34746

Phone: (407) 910-1459 Email: admissions@izzadeenacademy.org Website: www.izzadeenacademy.org
STUDENT INFORMATION
Student Name (Last, First, Middle)
Last Grade Completed
Grade Year
Gender (please circle one): M
Race (please check one): /Alaska Native,
Race (please check one): /Alaska Native,
White, Native Hawaiian/ Pacific Islander
Asian,
Black/African American,
Ethnicity (please check one)
Non -Hispanic
Hair Color
Eye Color
Eye Color
Height
Weight
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Home Phone
Format: (000) 000-0000.
Place of Birth
Place of Birth
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State: FL Zip Code
Primary language spoken at home
PREVIOUS SCHOOL INFORMATION
Name of School
Address
Address
Phone
Format: (000) 000-0000.
Fax
Dates attended

MonthDayYear
Date
Izzadeen Academy
4992 W. Irlo Bronson Memorial Hwy; Kissimmee, FL 34746

Phone: (407) 910-1459 Email: iadmissions@izzadeenacademy.org Website: www.izzadeenacademy.org
PARENT/LEGAL GUARDIAN INFORMATION
Primary Guardian Information: Secondary Guardian Information:
Name
Name
Relationship
Relationship
Relationship
Relationship
Home Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Email
example@example.com
Occupation
Occupation
Place of Employment
Place of Employment
The child resides with: Child’s custody with:
Both ParentsMotherFatherOther
Place of Employment
If the child is not living with both parents, the legal guardian must provide a proof of guardianship and fill
I/We legal authority and the corresponding duty in regard to his/her education.
am/are the legal custodian(s) of
, and has/have
I certify that the information given in this application is complete and accurate, and understand to make false statements within this application may result in the withdrawal and/or termination of admission. I agree to support and abide by the Izzadeen Academy regulations, policies, and guidelines for admissions and attendance.
Primary Guardian Printed name
Primary Guardian Signature

Clear
Date

MonthDayYear
Date
Secondary Guardian Printed Name
Secondary Guardian Signature

Clear
Date

MonthDayYear
Date
Izzadeen Academy
4992 W. Irlo Bronson Memorial Hwy; Kissimmee, FL 34746

Phone: (407) 910-1459 Email: iadmissions@izzadeenacademy.org Website: www.izzadeenacademy.org
EMERGENCY CONTACT / MEDICAL INFORMATION
Student Name
Grade
Parents are required to provide an emergency contact (someone other than the parent) in the event that the parent cannot be reached.

Emergency contact must be someone who resides in local area.
Name
Phone
Format: (000) 000-0000.
Relationship
Phone
Format: (000) 000-0000.
Phone
Format: (000) 000-0000.
Relationship
Physician’s Name
Office Phone
Format: (000) 000-0000.
Preferred Hospital
your child have any known medical condition(s)? NO
YES
If yes please explain
Does your child have any allergic reaction to any of the following?
Medications: No Yes Reaction
No Yes Reaction
Insect Bite: No Yes Reaction
Other: No Yes Reaction
Are any of the above allergies severe or life-threatening? NO
If yes, please explain
In addition to students’ academic success, the health and safety of our students is of utmost importance to us. In order to foster the student’s safety, we will no longer be administering over the counter medication; this includes and is not limited to Advil, Tylenol, Pepto Bismol and Benadryl. The school administration will however assist in administering Medication that is prescribed by a physician. To do so the school must receive written directions from the physician along with a signed request from the parent. At the end of the school day the parent must pick up the medication from the school. No medication may be left overnight. Please contact the school if you should have any questions.
Emergency Care
- In the event of an emergency, I authorize IZZADEEN ACADEMY staff to provide any first aid care deemed necessary for my child.
- In the event of an emergency, I authorize IZZADEEN ACADEMY staff to transfer my child’s health record to the local hospital or emergency facility.
- The State of Florida requires a notarized medical release form prior to emergency medical treatment. In the event of injury to my child requiring immediate medical attention, if I/we cannot be reached, IZZADEEN ACADEMY has my permission to take him or her for treatment at the closest hospital.
I understand that the school personnel are not held liable for the administration of any medication(s) or for its possible side effects. I hereby give permission to dispense the ADHD prescribed medication(s), in accordance with the written directions from the physician
Primary Guardian Printed Name
Primary Guardian Signature

Clear
Date

MonthDayYear
Date
Secondary Guardian Printed Name
Secondary Guardian Signature

Clear
Date

MonthDayYear
Date
Izzadeen Academy
4992 W. Irlo Bronson Memorial Hwy; Kissimmee, FL 34746

Phone: (407) 910-1459 Email: admissions@izzadeenacademy.org Website: www.izzadeenacademy.org
PARENTAL PERMISSION FOR DATA PUBLICATION
Student Name
Grade
IZZADEEN ACADEMY is requesting your permission to share your contact information for organizing school wide events.

We are also requesting permission to capture picture(s) of you and /or your child for purposes of the year book and other internal school related publication(s

If you agree with the above, please check all the items below that you agree with for publishing and/or sharing purposes, and sign below.

Please check YES/NO to all items below that you agree with to be used for internal publishing: I /we give permission to the following:
YES
NO
Child’s photograph taken for the use of ID card

Child’s photograph taken & released for publishing in the year book

Child’s photograph taken & released for publishing in other school related materials

Student Home phone number released for publishing in school related materials

Primary Guardian/ Mother’s cell phone number released for publishing in school related materials

Primary Guardian/ Mother’s email released for publishing in school related materials

Primary Guardian/Mother’s photograph taken & released for publishing in the year book and/or other school related materials

Secondary Guardian /Father’s cell phone number released for publishing in school related materials

Secondary Guardian/Father’s email released for publishing in school related materials

Secondary Guardian/Father’s photograph taken & released for publishing in the year book and/or other school related materials

PHOTOGRAPHS, VIDEOS AND AUDIO TAPES: I give IZZADEEN ACADEMY permission to photograph and/or record my child on audio or video for security purposes. I also understand that I must have written permission before capturing any images or audio recording of the other children in the school.
Primary Guardian Printed Name Primary Guardian Signature
Primary Guardian Signature

Clear
Date

MonthDayYear
Date
Secondary Guardian Printed Name
Secondary Guardian Signature

Clear
Date

MonthDayYear
Date
Izzadeen Academy
4992 W. Irlo Bronson Memorial Hwy; Kissimmee, FL 34746

Phone: (407) 910-1459 Email: admissions@izzadeenacademy.org Website: www.izzadeenacademy.org
STUDENT DROP-OFF / PICK-UP - ADD/DROP FORM
I/ We
and
the legal guardian(s) of
, grade
, grant permission to the individual(s) listed below to
drop him/her off and pick him/her up to and from school without the need of prior approval.

Use the space below to ADD individual(s) to your drop off/pick-up list.
Name
Name
Relationship
Phone Number
Format: (000) 000-0000.
Name
Relationship
Phone Number
Format: (000) 000-0000.
Name
Relationship
Phone Number
Format: (000) 000-0000.
Name
Relationship
Phone Number
Format: (000) 000-0000.
Name
Relationship
Phone Number
Format: (000) 000-0000.
- For all children’s safety, it is critical for you or your authorized pick-up individuals to use your dismissal card to pick up your child. To ensure the safety of our school’s staff and children, please keep your card in secure location.
- Please notify your authorized pick-up individuals that they must bring government-issued identification when they pick up your child. If your child(ren) is/are picked up after dismissal has ended, a late pick-up fee of $5.00 for every 10 minutes will be added to your monthly invoice.
- If your child(ren) is/are not picked 15 minutes after dismissal has ended, he/she/they will be placed in our after-school care program and you will be invoiced accordingly.
- IZZADEEN ACADEMY reserves the right to contact and request the individuals listed above to pick up your child if he/she is not picked up by 6:00pm. In such cases, local authorities may be contacted.
Anyone not on this list MAY NOT pick up your child(ren) without prior approval from the parents or legal guardian.

NO EXCEPTIONS. This is for the safety of all our students.
Primary Guardian Printed Name
Primary Guardian Signature

Clear
Date

MonthDayYear
Date
Secondary Guardian Printed Name
Secondary Guardian Signature

Clear
Date

MonthDayYear
Date
RELEASE OF STUDENT RECORDS
To
Last School Attended
Address

Address

Street Address Line 2

CityState Zip

Postal / Zip Code
State Zip
Phone
Format: (000) 000-0000.
Fax
Email Contact Person
example@example.com
Email Contact Person
example@example.com
This is a request for all pertinent information concerning the student(s) named below who has applied for admission to our school. Please forward records via email, fax or mail to the above information.
Transcript of Grades/Report Card Standardized Test Score
Transcript of Grades/Report Card Standardized Test Score
Transcript of Grades/Report Card Standardized Test Score
Grades at time of withdrawal
Attendance Records
Detailed Student Profile Attendance Records
Intellectual / Psychological Evaluations
Birth Certificate
Grading System
Social History / IEP / 504
Special Education Data

Any further information you can give us to enable proper placement will be appreciated. If these records are not available at your school, please advise accordingly.

Rows	Last Name	First Name	Date of Birth	Current Grade	Gender M/F

Thank you for your cooperation.
Registration Administration
Date

MonthDayYear
Date
Should be Empty:

Registeration Form

Last Name First Name Grade

Grade 1 - 9

STEP UP FOR STUDENTS (SUFS) SCHOLARSHIP INFORMATION

Izzadeen Academy

STUDENT INFORMATION

PREVIOUS SCHOOL INFORMATION

Izzadeen Academy

PARENT/LEGAL GUARDIAN INFORMATION

Izzadeen Academy

EMERGENCY CONTACT / MEDICAL INFORMATION

Emergency Care

Izzadeen Academy

PARENTAL PERMISSION FOR DATA PUBLICATION

Izzadeen Academy

STUDENT DROP-OFF / PICK-UP - ADD/DROP FORM

Name

RELEASE OF STUDENT RECORDS

Last School Attended