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Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Primary Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Is your child a US Citizen/Permanent Resident (Green Card)? *

Yes

No

Does your child speak and understand english?

Yes

No

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Father/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

US Citizen/Green Card Holder *

Yes

No

Mother/Guardian Name *

First Name

Last Name

Phone Number *

(###)

###

####

US Citizen/Green Card Holder *

Yes

No

Emergency Contact (1) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Emergency Contact (2) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Is the Father Employed? *

Yes

No

Is the Mother Employeed? *

Yes

No

Are you Zakat Eligible? *

Yes

No

Are you Applying for Financial Aid? (If yes, please fill out the Financial Aid form). *

Yes

No

Application date *

MM

DD

YYYY

Please confirm the following: *

I have submitted all form required for registration, as indicated in the Student Registration Checklist.

*

I have read and signed the Financial Responsibilities form.

*

I have read and signed the Student Discipline Policy.

*

I have read and signed the Student Handbook Acknowledgment form.