Admission form – Zakariyya Masjid

Admission form for the Zakariyya Islamic Centre Evening Arabic Classes.

Applicants Details:

Surname

Forename

Address

Postal Code

Date of Birth

Parent Surname

Parent Forename

Parent Address

Postal Code (Parent)

Parent Occupation

Parent Contact No

Emergency Contact No

Previous Education of the student. Briefly state the name and address of the school or masjid attended and educational achievements

Health. Dose Applicant suffer from any serious or long term illness?

Describe in detail if 'Yes'

Briefly Describe the illness of student if any. otherwise leave it blank

Dose He/She suffer from any allergies?

Describe in detail if 'Yes'

Briefly Describe the type of allergy of student if any. otherwise leave it blank

Dose the applicant require any special needs? (Educational or Health)

Describe in detail if 'Yes'

Briefly Describe if applicant require any special need. otherwise leave it blank

Phone

Deliration:

The information which I have given in this form are true and complete to the best of my knowledge. I understand that my application will be disqualified if I have knowingly given false information. I have read or have been explained and understand all the questions, rules and regulations.