Al-Furqan Academy's Registration Form

1

Student Name* This field is required.

First Name

Middle Name

Last Name

2

Birth Date

3

Gender* This field is required.

4

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

5

Who does the student live with?* This field is required.

6

Father's E-mailPlease provide updated email

7

Father's Phone Number* This field is required.Please provide the updated phone number

Area Code

Phone Number

8

Mother's E-mailPlease provide updated email

example@example.com

9

Mother's Phone Number* This field is required.Please provide the updated phone number

Area Code

Phone Number

10

Home Phone Number

Area Code

Phone Number

11

Student Ethnicity- Is the student Hispanic/Latino?* This field is required.

YESNO

12

Student Race- Please select the correct option from the list* This field is required.

13

Grade Level* This field is required.Please select the grade your child will be attending in upcoming school year

Select grade from the list

14

Sibling enrolled at AFA and grade lever (if none, write N/A)* This field is required.

15

Siblings not enrolled at AFA and grade level (if none, write N/A)* This field is required.

16

Student Allergy Information- List any known medical or dietary needs of the student (if none, write N/A)* This field is required.

17

Last School Attended* This field is required.

18

Was the student suspended or expelled from the previous school?* This field is required.

YESNO

19

Emergency Care Policy: Please Read Carefully

I, parent of student listed in this application, hereby authorize staff and officials of Al-Furqan Academy to contact authorized emergency contacts, provided by parents, on this form to provide necessary treatment in an emergency.

In the event the parents and authorized persons listed on this form can not be reached, the school officials are hereby granted authorization to take whatever actions deemed necessary for the health of my child.

I assume full financial responsibility for the emergency care and/or transportation for my child and will NOT hold Al-Furqan Academy officials and staff responsible.

20

Emergency Care Policy:* This field is required.Please select from the list

Parent name required

21

Emergency Contacts & Authorized Persons:

I hereby grant permission for Al-Furqan Academy staff to release my child to the following persons listed in the next section. The following people will also be contacted and are authorized to act on mu behalf as well as remove the child from the facility in case of illness,accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached.

Please provide atleast two emergency contacts in next section

22

Emergency Contact & Authorized Persons1st emergency contact

First and Last Name

Please enter updated phone number

Please enter emergency contact's email if any

Relationship to student's parents

23

Emergency Contact & Authorized Persons2nd emergency contact

First and Last Name

Please enter updated phone number

Please enter emergency contact's email if any.

Relationship to student's parents

24

Computer Usage - I give my child permission to use AFA computers for academic purposes. I understand that my child may lose this privilege if inappropriate use of computer detected.* This field is required.

YESNO

25

Pictures- I give my child permission to have his/her picture taken for school promotions, school website, classroom activities, etc..* This field is required.

YESNO

26

Field Trips- I agree to release and discharge Al-Furqan Academy and its respective members, officials, officers, employees and agents, exercising reasonable care within their scope of employment, from liability growing out of personal injuries and propety damage resulting or occurring during the filed trip activities, or in transit to and from said activity.* This field is required.

YESNO

27

By entering my name below, I certify I am the parent or legal guardian of the sudent named in this registeration form and all the information is true and correct to the best of my knowledge.* This field is required.Parent/ Legal Guardian: Enter your legal name in the field below.

Parent/ Legal Guardian: Enter your legal name in the field