DUA Student Enrollment Form
Student Information
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
DUA Program
Enrolled Program *
Parent/Guardian Informaton
Parent/Guardian's Name *
(First and Last)
Your answer
Relationship *
Your answer
Address *
Your answer
Phone *
(Primary)
Your answer
Phone
(Alternate)
Your answer
Email *
Your answer
Emergency Contact
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Authorized pick-up and drop-off person(s) contact Information:
Name *
(Primary)
Your answer
Contact Phone *
(Primary)
Your answer
Name
Alternate
Your answer
Contact Phone
(Alternate)
Your answer
Medical Information
Doctor Name *
Your answer
Phone
Your answer
Clinic/Hospital Name *
Your answer
Phone *
Your answer
Allergies/Medical Problems:
Your answer
Medication
Your answer
Other Siblings Enrolled in DUA
Every student should have their own application. Other Sibling Information is for Tuition Discount Recognition Purposes Only
Student 1: Full Name
Your answer
Student 2: Full Name
Your answer
Student 3: Full Name
Your answer
Student 4: Full Name
Your answer
Student 5: Full Name
Your answer
Student 6: Full Name
Your answer
In case of an emergency, when the school is unable to locate a parent or a guardian, I authorize DUA personnel to resort to medical treatment for my child and to make whatever arrangements that deems necessary at the parent's cost. *
Tuition Fees
Please refer to section under Hifz Programs for tuition fee details (http://darululoomaustin.org/hifz-programs/)
Financial assistance available for eligible students. If financial assistance is required, please send request to darululoomaustin@gmail.com. Approval of financial aid is required prior to enrollment.
Does the student require financial assistance? *
Darul Uloom Austin Contact Information
Mailing Address: P.O. Box 80914 Austin TX 78708
Phone: (512) 956-6DUA or (512) 299-6947
Email: darululoomaustin@gmail.com
Web: www.DarulUloomAustin.org
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