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Full Name of Child:
Full Name of Primary Guardian:
Email

** The Signature of the parent is required on ALL forms and initials on some. ** Please read carefully then fill and sign accordingly.

Elementary & Middle School Admission
* Registration Form
* Physical Activity Statement
* Media Release
* Hifz Program Registration - Optional
* Child Care Sick Policy
* Authorization for Emergency Treatment Form
* Parent responsibility form
* Student Records Release Form
Student Birth Certificate
Florida Certification of Immun¬ization: Form DH-680
OR
Religious Exemption Statement Form DH-681 Signed by The Florida Department of Education
School Health Entry Form: DH -3040
Registration Fee
Scholarship Award Letter - If Applicable

Student Information

Name
Gender
Address
MM slash DD slash YYYY
Race:
Student Living with:

school and Academic History

School Type:
Address
MM slash DD slash YYYY
MM slash DD slash YYYY
Has the student ever attended a full time islamic school before?
Has the student ever experienced any disciplinary issues, including suspension, at school?
Does this student have any special educational needs?

Parent / Guardian Information

Marital Status:
Primary Guardian Name:
Secondary Guardian Name:
Address (if different from student)

Sibling Information

Sibling 1 Name:
MM slash DD slash YYYY
Sibling 2 Name:
MM slash DD slash YYYY
Sibling 3 Name:
MM slash DD slash YYYY

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