Admission

Applicant Section

First Name *
Last Name *
Gender *
Home Address
City *
Zip Code *
Date of Birth *
Age *
Languages Spoken *

Parent/Guardian Section

Father’s First Name *
Father’s Last Name *
Home Address
City *
Zip Code *
Home Phone *
Mobile Phone *
Email Address *
Mother’s First Name *
Mother’s Last Name *
Home Address
City *
Zip Code *
Home Phone *
Mobile Phone *
Email Address *

Additional Emergency Contact

First Name *
Last Name *
Home Address
City *
Zip Code *
Home Phone *
Mobile Phone *
Email Address *

Medical History

Details of any Medical Condition(s): *
Details of any medication(s) currently in use: *
Any other information or allergies: *

Details of Previous Islamic Education

Name of Institution/or Teacher’s Name *
Home Address
City *
Zip Code *
Amount of Nazera Completed *
Amount of Hifz Completed *
List of Islamic Books Completed/Studied (Arabic, English, and Urdu) if applicable: *
Reason for leaving *