Iqra Student Registration

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Iqra Academy Student Registration



	There is a $25 (non-Refundable) Registration Fee per child.
	Student Information
	Name* First Name Middle Name Initial Last Name
	Address* City State Zip Code		Home Phone* Please enter numbers only.
	Date of Birth* Month Day Year	Birth Place*	Ethnic Background*
	Grade*	Gender* Male Female	Language Spoken at Home*
	Do you give Iqra Academy the permission to take photographs and/or video of the student, to be used in the classroom, for educational or promotional purposes and/or public awareness of our school?* Yes No


	Parent/Guardian Information
	Father's Name* First Name Last Name	Place of Employment* Father's	Phone Father's
	Email Father's
	Mother's Name* First Name Last Name	Place of Employment* Mother's	Phone Mother's
	Email Mother's
	Guardian's Name (if applicable) First Name Last Name	Place of Employment Guardian	Business Phone Guardian
	Student lives with* Both Parents Mother Father Other: Other Value


	Emergency Contact Person to call In Emergency if parents cannot be reached at Home or Work.
	Name First Name Last Name	Phone Number	Relation Ship to Student
	Name First Name Last Name	Phone Number	Relation Ship to Student
	Name First Name Last Name	Phone Number	Relation Ship to Student
	Student's Special Health Problems
	Health Insurance


	Brothers and Sisters living at home
	Name First Name Last Name	Date of Birth Month Day Year	School
	Name First Name Last Name	Date of Birth Month Day Year	School
	Name First Name Last Name	Date of Birth Month Day Year	School
	Name First Name Last Name	Date of Birth Month Day Year	School

Please type the word above

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