Quran & Islamic Studies – Application Form

Student Details

Child 1

First Name: Middle Name: Surname: Date of Birth: Age: Gender: Boy Girl

Child 2

First Name: Middle Name: Surname: Date of Birth: Age: Gender: Boy Girl

Child 3

First Name: Middle Name: Surname: Date of Birth: Age: Gender: Boy Girl

Child 4

First Name: Middle Name: Surname: Date of Birth: Age: Gender: Boy Girl Full Address: Home Language: Previous Islamic Education Centre / Masjid attended: Address: Post Code:

Parent / Guardian Details

Full Name: Relation to the Child: Full Address (if different): Home Number: Mobile Number: Work Number: Email:

Medical Consent

Name of GP: GP Clinic Address: Post Code: Telephone Number:

Emergency Contact Details

First Name: Surname: Full Address: Post Code: Mobile Number: Home Number:

Health & Special Requirements

Special educational or other needs (mention child): Allergies (mention child): Medical conditions (e.g., dyslexia): History of social services involvement: Behavioural history:

Declaration

I hereby declare that I have read the admissions rules and agree to abide by all AEC rules and regulations. I confirm that the information provided is accurate.

Full Name of Parent/Guardian: Signature (type name): Date:

Permission for Children to Go Home Alone

Name of Child 1: Name of Child 2: Name of Child 3: Permission: -- Please choose an option -- I DO give permission I DO NOT give permission Parent Name: Signature (type name):