"Lighting a Pathway to 21st-Century Leadership Through Academic and Moral Excellence"

Additional documents for registration

Bring this registration form and the following documentation to the school office.

  • Original Certified Birth Certificate
  • Current Immunization Form
  • Recent Report Card, or Student Records

Student Information

    First Name

    Last Name

    M.I.

    Birth Date

    Gender

    Ethnicity

    Entry Year

    Grade in Fall

    Have you previously applied to or attended this school?

    If yes, what year?

    Current Residence Information

    Street Address

    Street Address Line 2

    City

    State

    Zip Code

    Home Phone Number

    Cell Phone Number

    E-mail Address

    Parent/Guardian Residence Information (if different from above)

    Parent or Guardian Name

    Street Address

    Street Address Line 2

    City

    State

    Zip Code

    Emergency Contact 1

    First Name

    Last Name

    Primary Phone Number

    Secondary Phone Number

    Emergency Contact 2

    First Name

    Last Name

    Primary Phone Number

    Secondary Phone Number

    Physician and Medical Information

    First Name

    Last Name

    Primary Phone Number

    Secondary Phone Number

    Preferred Hospital

    Insurance/Health Coverage (Company)

    Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health conditions.

    Enrollment History

    Previous School 1

    School Name

    City

    State

    Date Started

    Date Ended

    Previous School 2

    School Name

    City

    State

    Date Started

    Date Ended

    Tell us about your child

    What do You feel are your child's talents, abilities and any challenges he/she may have?

    List any awards, achievements and or extra curricular activity that your child is involved in.

    Does your child currently have one of the following?

    Any additional information that you would like to tell us about your child.

    Tell Us About You

    Mother or Guardian Occupation

    Father or Guardian Occupation

    Please list any expertise or talents you can volunteer to the school to fulfill parent hours.

    Child is currently living in home with:

    How do you think your child(ren) will benefit from an Islamic education?