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Ayesha Academy General Admission Form
Required Paperwork with this form is:
1. Copy of Birth Certificate.
2. Immunization Records for Child.
3. Vision Screening test.
4. Application/Registration fee $250 per child (Checks payable to Masjid Madinatul Ilm)
Student First and Last name: *
Your answer
Gender: *
Date of Birth: *
MM
/
DD
/
YYYY
Father's Name and Phone number *
Your answer
Mother's Name and Phone number *
Your answer
Address (Street Address, City, State, Zipcode): *
Your answer
Home Phone: *
Your answer
Emergency Name & Contact Information *
Your answer
Grade Entering (2018-2019 Academic Year) *
Your answer
Nazira of Quran Completed? *
Any portion of Quran Memorized? If Yes, How much?
Your answer
Previous School and Grade attended *
Your answer
Ethnic Background/Language: *
Your answer
In case of any emergency please provide the child's physicians name and contact information *
Your answer
Any Medical/Health Problems/Allergies/or any Issues? *
Your answer
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