Student application form

Section 1: Student Information

Name*

Full Name

Gender*

Grade*

Returning Student*

Yes
No

Date of Birth*

Social Security Number(SSN)*

Address*

Street Address City State ZIP Code

Section 2: Family Information

Father's Name

First Last

Address (if different from student)

Street Address City State ZIP Code

Phone

Email

Employer Name/Profession

Mother's Name

First Last

Address (if different from student)

Street Address City State ZIP Code

Email

Employer Name/Profession

Legal Gaurdian Of Child

First Last

Siblings Information

Name

Age

Grade

Name

Age

Grade

Name

Age

Grade

Section 3: Pick up Policy and Authorization Form

Parents will be contacted before any listed person.

Name
First Last

Phone

Relationship

Name
First Last

Phone

Relationship

Name
First Last

Phone

Relationship

Permission to Pickup
I give my permission to the following people to pick up my child/children from Manarah Islamic Academy. Parents will be contacted before any listed person.

Section 4: Emergency Contact and Medical Authorization Form

Authorize any employee staff of Manarah Islamic Academy to take my child to the nearest hospital for emergency-related medical treatment. I agree to hold Manarah Islamic Academy harmless for any unforeseen accident in the school or on the school grounds.
I agree

Name
First Last

Phone

Relationship

Name
First Last

Phone

Relationship

Name
First Last

Phone

Relationship

Section 5: Parent Consent

I agree to indemnify and hold harmless Manarah Islam ic Academy, COE (Council of Education), BOD (Board of Directors), school teachers, principal, staff, and all volunteers, as well as the MALV (Muslim Association of Lehigh Valley), its BT (Board of Trustees), EC (Executive Committee), and all its members in the event my child(ren) is/are injured or harmed in any way while he/she/they is/are on the premises of Manarah Islamic Academy, located at 1988 Schadt Ave nue, Whitehall, PA 18052. I will also be responsible for the cost of repair and/or replacement for any damage to the School and other Manarah facilities that is caused by my child(ren). My child(ren) and I will further comply with the rules and regulations governing the operation of Manarah Islamic Academy and MALV.
I agree

Name
First Last

Section 6: Medical Information

Does your child have medical problems or allergies (food, medicine, etc.). If so, please list

Yes

No

Does your child take any medications on a regular basis? If so, please list:

Yes

No

Name
First Last

Phone

Fax

Insurance Name
Name

Name of Policy Holder
full name

Policy Number

Income Sources

1st Parent/Guardian

Social Security Benefits, SSI or Disability Income

Taxable Income

Expenses

Other Additional Income

CAPTCHA

Section 1: Student Information

Section 2: Family Information

Siblings Information

Section 3: Pick up Policy and Authorization Form

Section 4: Emergency Contact and Medical Authorization Form

Section 5: Parent Consent

Section 6: Medical Information

Income Sources

1st Parent/Guardian