MICC Student Enrolment Form – Molesey Islamic Cultural Centre

MICC Madrashah Student Enrolment Form

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1 / Guardian 1 / Carer 1 Name*

First NameLast Name
Relationship to Student*
If other? what is the relationship?*
Email address*
example@example.com
Mobile Number *
Please enter a valid phone number.
Parent 2 / Guardian 2 / Carer 2 Name

First NameLast Name
Relationship to Student*
If other? what is the relationship?*
Email Address
example@example.com
Mobile Number
Please enter a valid phone number.
In case of emergency contact which parent?*

Parent OneParent Two
Is there a disability / allergy / serious condition / learning difficulty which we need to know about? If NONE then please state NONE*
Any Additional Information for Student we must be made aware of? If NONE then please state NONE*
Consent of Child / Children Photo form signed and completed and has consent give to MICC Madrashah?*

YesNo
Has the parent given consent for the the child have permission to go home on their own?*

YesNo
MICC Madrashah has your consent to contact you via SMS/WhatsApp/Email?*

YesNo
Please verify that you are human*
Should be Empty:

	No of classes each Children attending?
Classes per week? 1 = 4 classes per month
Classes per week? 2 = 8 classes per month
Classes per week? 3 = 12 classes per month

	Which days your children will be attending?
Wednesday
Thursday
Firday