Madressa Registration Form

Registration Form 2017-2018 ; Az-Zahra Islamic School

(Section A) Family Information

Family's Last Name *

Mother's Name *

Father's Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone # * 🛈

Mother's Cell Phone * 🛈

Father's Cell Number * 🛈

Mother's Email *

Re-Type Mother's Email to confirm *

Father's Email

Re-Type Father's Email to confirm

(Section B) FEES - ONLY fill this section if Paying Fees by Credit Card. DO NOT FILL this section if paying fees by cash or check.

If you will be paying fees by Cash or Check, please SKIP this section completely. DO NOT fill out anything. When you complete the form, please click 'SUBMIT' & on the next page click 'CONFIRM' order with a total of $0.00 & you are done!

If paying fees by credit card, After you fill the form, please click 'SUBMIT' at the end, you will be directed to an 'Order Summary' page where you will see your total. Please click on 'Check Out with PAYPAL'. This will take you to a PayPal page, where you can either login if you have a Paypal account, OR select 'Pay with Debit or Credit Card' and enter your credit card information.

The Fee amount for this school school year is as follows : Family of 4 Children=$500.00 / Family of 3 Children=$450.00 / Family of 2 Children=$400.00 / Family of 1 Child=$350.00 / If you would like to pay your fees by cash or check, PLEASE DO NOT fill out this section. Just continue to section C.

Please Select Number of children in your family. If you wish to donate any additional funds towards Madressa, please specify that in 'Additional Donation' (Click 'CALCULATE' to see your total amount due) 🛈

Family of 4 Children

Family of 3 Children

Family of 2 Children

Family of 1 Child

Additional Donations

(Click ONLY IF PAYING BY CC) Current Total:

$0.00

(Section C) Student Information - Please Fill out information for EACH child you are registering.

1st Child's information

1st Child-Name *

1st Child-Date of Birth * +

Any Allergies or Medical info you need to share - If NONE please type 'NONE' * 🛈

1st Child-Email address if any

2nd Child's Information (Leave Blank if only 1 child)

2nd Child-Name

2nd Child-Date of Birth +

Any Allergies or Medical info you need to share - If NONE please type 'NONE' 🛈

2nd Child-Email address if any

3rd Child's Information (Leave Blank if only 2 children)

3rd Child-Name

3rd Child-Date of Birth +

3rd Child-Any Allergies or Medical info you need to share - If NONE please type 'NONE' 🛈

3rd Child-Email address if any

4th Child's Information (Leave Blank if only 3 children)

4th Child-Name

4th Child-Date of Birth +

4th Child-Any Allergies or Medical info you need to share - If NONE please type 'NONE' 🛈

4th Child-Email address if any

(Section D) Emergency Contacts - PLEASE provide 2 Emergency contacts who are NOT THE PARENTS

Emergency Contact 1 - MUST NOT BE THE PARENTS' INFORMATION

Last Name (Emergency Contact 1) * 🛈

First Name (Emergency Contact 1) *

Street Address (Emergency Contact 1) *

Address Line 2 (Emergency Contact 1)

City (Emergency Contact 1) *

State *

Zip Code *

Home Phone # 🛈

Cell Phone * 🛈

Alternate Number 🛈

Emergency Contact 2 - MUST NOT BE THE PARENTS INFORMATION OR THE SAME AS THE FIRST EMERGENCY CONTACT

Last Name (Emergency Contact 2) *

First Name (Emergency Contact 2) *

Street Address (Emergency Contact 2) *

Address Line 2 (Emergency Contact 2)

City (Emergency Contact 2) *

State *

Zip Code *

Home Phone # 🛈

Cell Phone * 🛈

Alternate Number 🛈

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