Read Madrasah%20Admission%20Form.pdf text version

1320 S. Nurery Road, Irving, TX 75060-6116 - e-mail: [email protected]

Al Madrasa-tul-Burhaniyah - Dallas

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STUDENT REGISTRATION FORM STUDENT'S INFORMATION

New Returning

TO BE COMPLETED BY THE PARENT OR GUARDIAN

Date: Student ID:

Male Female

Last Grade Completed (if returning student):

Student's eJamaat ID: Student's Legal Name:

(From Birth Certificate) Last mm/dd/yyyy First Middle

Student's Date of Birth:

Grade Level in Regular School:

PARENTS' INFORMATION

Head of Household eJamaat ID: Father's Name:

Last First (Home Phone No.) Middle (Work Phone No.) (Cell Phone No.)

Father

Mother

Contact Information:

Mother's Name:

Last

First (Home Phone No.)

Middle (Work Phone No.) (Cell Phone No.)

Contact Information:

Address: Primary Email Address:

City:

State:

Zip Code:

OTHER CHILDREN IN THE FAMILY

Child's Name Madrasa Attending / Grade (if not, N/A)

Atfaal

Atfaal

Atfaal

EMERGENCY CONTACTS

List two local contacts to whom the student may be released in the case of illness or other emergency if unable to notify parent. Contact # 1 Phone Cell Phone Relationship Aamil Saheb's Signature: Date Parent's Signature: Contact # 2 Phone Cell Phone Relationship Head Moallim's Signature: Date Date

This form MUST be completed, signed and returned with full payment by September 26th 2009. If payment is not received in full your child will not be registered for the upcoming Madrasa year and will NOT be allowed to attend Madrasa. If paying in installments, a maximum of 4 post-dated checks will be accepted with the first one dated 10/10/09 and the last dated no later than 01/15/10. Thank you for your cooperation.

OFFICE USE

Name on Check Name on Check Name on Check Name on Check Check # Check # Check # Check # Check Date Check Date Check Date Check Date Amount Amount Amount Amount

Student Registration Form v0.2.08.31.09

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