Assalam Islamic School Registration Form
Registration and Book fee is $25.00/child
Email address *
Date *
MM
/
DD
/
YYYY
Mother’s Name *
Mother's email *
Mother's Phone Number *
Father’s Name *
Father's email *
Father's Phone Number *
Address *
For emergency, please contact: *
Other contact name (if parent cannot be reached). *
Other contact phone number (if parent cannot be reached. *
Child’s Full name *
Child's Date of Birth *
Age *
Gender *
New student or returning student *
Does your child have a medical condition or allergy that you want the school to be aware of? *
If you answered “Yes", in the previous question, please list medical condition or allergy:
Is there any other information about your child that you feel would be helpful for us to know? Please tell us below:
SELECT PROGRAM CHOICE *
Are you registering another child?
Clear selection
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