Enrolment « Kashiful Uloom

Course *

Name *

First

Middle

Last

Gender *

Male
Female

Age *

Date of Birth *//

Email *

Contact Number *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Prior Education

Prior Islamic Education

Prior Qurʾān Learning

Mazhab (School of Thought) *

Level of Proficiency in Qurʾān *

Parent/Guardian Details

Parent/Guardian 1 Name *

Contact Number *

Email *

Relationship to Student *

Parent/Guardian 2 Name *

Contact Number *

Email *

Relationship to Student *

Student Medical Information

Does the student have any disability? *

Yes
No

e.g., intellectual, sensory, physical impairment or behavioural. If Yes, please provide details below:

Please specify the disability *

Does the student any allergies? *

Yes
No

e.g., intellectual, sensory, physical impairment or behavioural. If Yes, please provide details below:

Please list the allergies *

Has the student been diagnosed or at risk of Anaphalaxis? *

Yes
No

If YES, does the student have an auto injection device (e.g. EPIPEN)?

Yes
No

Please list things that might trigger an anaphylactic reaction: *

Does the student have Asthma *

Yes
No

If, Yes you must provide an Asthma Action Plan and send medication with the student when they are attending the madrasa.

Does the student have any other medical conditions or special needs?

Yes
No

e.g. epilepsy, diabetes, etc. Please provide details below and contact the administration.

Please list all other medical conditions and special needs: *

Signature

By ticking this box, I agree that the information provided above is true and correct.

Student/Guardian Name *

Date of Submission *//