Madrasah Registration Form

Madrasah Registration Form

Complete the parent/guardian, student, medical, support, and consent details, then review and sign the declaration at the end.
Parent/Guardian Details
Primary Guardian Full Name

First NameLast Name
Primary Guardian Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Guardian Email Address
example@example.com
Relationship to Student
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Guardian Full Name

First NameLast Name
Secondary Guardian Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Guardian Email Address
example@example.com
Secondary Guardian Relationship to Student
Additional Emergency Contacts
Student 1 Details
Student Full Name

First NameMiddle NameLast Name
Gender
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Primary Language Spoken at Home
Current Qur'an/Madrasah Level
Previous Madrasah or Islamic Education (if applicable)
Medical & Health Information
Does the student have any diagnosed medical conditions?
If yes, please provide details of the medical condition(s)
Does the student have any allergies?
If yes, please provide details of the allergy(ies) and any known reactions
Does the student take any prescribed medication?
Is there anything staff need to know to safely support the student?
Learning, Behaviour & Development
Does the student have any diagnosed or suspected learning, behavioural, speech, hearing, or developmental condition?
If yes, which areas apply?

Other
Please provide further details
Upload a clear copy of the student's birth certificate

Cancelof
Do you have any other children you wish to register?
Student 2 Details
Student 2 Full Name

First NameMiddle NameLast Name
Gender
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Previous Madrasah or Islamic Education (if applicable)
Medical & Health Information
Does the student have any diagnosed medical conditions?
If yes, please provide details of the medical condition(s)
Does the student have any allergies?
If yes, please provide details of the allergy(ies) and any known reactions
Does the student take any prescribed medication?
Is there anything staff need to know to safely support the student?
Learning, Behaviour & Development
Does the student have any diagnosed or suspected learning, behavioural, speech, hearing, or developmental condition?
If yes, which areas apply?

Other
Please provide further details
Do you have any other children you wish to register?
Student 3 Details
Student 3 Full Name

First NameMiddle NameLast Name
Gender
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Primary Language Spoken at Home
Current Qur'an/Madrasah Level
Previous Madrasah or Islamic Education (if applicable)
Medical & Health Information
Does the student have any diagnosed medical conditions?
If yes, please provide details of the medical condition(s)
Does the student have any allergies?
If yes, please provide details of the allergy(ies) and any known reactions
Does the student take any prescribed medication?
Is there anything staff need to know to safely support the student?
Learning, Behaviour & Development
Does the student have any diagnosed or suspected learning, behavioural, speech, hearing, or developmental condition?
If yes, which areas apply?

Other
Please provide further details
Terms & Conditions
Acknowledgements
Declaration
Confirmation
Parent/Guardian Full Name

First NameMiddle NameLast Name
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Should be Empty:

Madrasah Registration Form

Parent/Guardian Details

Student 1 Details

Medical & Health Information

Learning, Behaviour & Development

Student 2 Details

Medical & Health Information

Learning, Behaviour & Development

Student 3 Details

Medical & Health Information

Learning, Behaviour & Development

Terms & Conditions

Declaration