Mithaq Parent Form
This form is designed to help us better understand your child’s unique personality, strengths, and areas of growth. We kindly ask that both parents fill it out together, if possible, to ensure the information is accurate and comprehensive. All details you provide will remain strictly confidential and will be used only to help us better support your child’s learning and development through the Mithaq program.
Full Name of Student
*
First Name
Last Name
Student's Grade and School
*
Grade
School
Date of Birth
*
-
Month
-
Day
Year
Date
1st Parent / Guardian Name
*
Full Name
Relation
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
2nd Parent / Guardian Name
*
Full Name
Relation
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long has your family been part of the local Muslim community?
Less than a year
1–3 years
4-7 years
8 + Years
How would you describe your family connection to the masjid or community programs?
Very active
Somewhat active
Occasionally attends
Rarely attends
How would you describe your child’s current relationship with Islam?
Strong and consistent
Growing and curious
Uncertain or questioning
Struggling / disconnected
Which Islamic education program is your child currently attending or has attended in the past?
Weekend Islamic School
Full-time Islamic School
After-school Qur’an Program
Private Tutoring (at home or online)
None
How would you describe your family’s general approach to faith and spirituality at home? (Please share briefly about prayer, discussion of values, etc.)
What are three words that best describe your child’s personality?
What are your child’s greatest strengths or positive qualities? (e.g., leadership, kindness, creativity, humor, responsibility)
What are areas where your child struggles or could use more growth and guidance?(e.g., confidence, time management, emotional control, social challenges)
How does your child usually express emotions like anger, sadness, or stress?
What motivates or inspires your child most?
How does your child usually spend free time? (include hobbies, online activities, sports, reading, etc.)
Does your child have a role model or someone they deeply admire? If yes, who and why?
What are some questions or concerns your child has expressed about faith or identity?
What do you hope your child will gain spiritually and personally from Mithaq Program at Qiam?
How can we as mentors and teachers best support your child’s journey?
If you could share one du‘a or wish for your child’s future, what would it be?
Is there anything else you’d like us to know about your child, your family, or your hopes for their faith journey?
Any medical, dietary, or learning considerations we should know about?
Emergency Contact (other than parent):
*
Full Name
Phone Number
Submit
Should be Empty: