Hafiz Anas' Qur'an Class Registration Form - Rev 10/2020

Thank you for your interest in enrolling your child in Qur'an institute at Islamic Center of Irvine! Please read the following information before proceeding.

There are four steps to ensuring your child's spot at Qur'an Institute:

1. Complete this registration form for child age 6 to 16 years old.

2. Provide your payment information to the office. If you are applying for Financial Aid, please visit the office to complete your payment after your financial aid package is completed.

3. For new and returning students: have your child assessed in Qur'an by the Shaykh and conduct a meeting with the him. This is Mandatory step for all students. We will contact you to set this up once you have completed steps 1 and 2.

4. Attend a Mandatory Orientation. More Details will be sent out to you, once your enrollment is finalized.

5. If at any time you you plan to take a vacation and still need to hold a spot for you or your child, you will be required to pay 50% of of the normal tuition until you/they return.

6. You cannot hold a spot(s) for more than two months. If you don't want to hold a spot, your child's name will be added to the end of the Waiting List.

7. The Islamic Center of Irvine (ICOI) reserves the right to enroll students at its discretion.

Please note that we can only accommodate 60 students this year.
Email address *
- Student Information -
Child's First Name *
Child's Last Name *
Child's Gender *
Child's Age *
Child's Date of Birth *
Are You a Former Student? *
Level of Reading *
Class Schedule: Please select one *
Classes are Tuesdays and Thursdays
If your child has any allergies, please explain below. *
- Parents/Guardians Information -
If not applicable, type N/A
Mother's Full Name *
Mother's Cell Phone Number *
Mother's Email
PLEASE MAKE SURE THE EMAIL YOU LIST IS CORRECT! Email is our primary form of communication, so incorrect email addresses make communication to parents about upcoming events very difficult.
Father's Full Name
Father's Cell Phone Number
Father's Email
PLEASE MAKE SURE THE EMAIL YOU LIST IS CORRECT! Email is our primary form of communication, so incorrect email addresses make communication to parents about upcoming events very difficult.
Home Address *
City *
Zip Code *
Home Phone Number *
- Emergency Contact Information -
If not applicable, type N/A
Name of Emergency Contact *
Relationship to Child *
Phone Number of Emergency Contact *
- Health Insurance Information -
Name of physician *
Physician phone number *
Insurance name *
Insurance policy number *
- Student's Development Information -
Does your child have any limitations that would hinder him/her from normal progress in a regular classroom? If so, please explain. *
Has your child ever been recommended to repeat a grade or receive tutoring or any special education? If so, please explain. *
Has your child ever been suspended? If yes, please explain when, why, and for how long. *
- Payment Authorization -
** All payments must be made through credit/debit card or checking/savings account. We cannot accept cash.
** A one-time payment of $30 for registration will be charged with the first month's Payment.
** Monthly tuition payments of $80 will be charged automatically on the first of each month.

Financial aid is available to those who request it via the Community Assistance Program (CAP). Those previously approved for Financial Aid are not automatically approved for this year. It is required for a new application for Financial Aid to be submitted every school year in order to be considered for Financial Aid.
By checking the box below, I authorize the Islamic Center of Irvine (ICOI) to withdraw funds from my account to cover the tuition payments for this class. *
By checking the box below , I understand that no refunds are allowed after the first day of school. Students may be withdrawn at any time, but no refund will be given for any tuition/registration fee that has already been paid. *
By checking the box below ,I understand that the school is not responsible for any injuries that may occur during school time at ICOI. *
I understand that this form does not hold my child's place until I attend the orientation session, submit my payment information to the office, and I receive an email confirmation from Sh. Anas (or his designee) that my child has been accepted. *
By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
A copy of your responses will be emailed to the address you provided.
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