Student Details: Please complete for each child to be enrolled

Student 1

Student 1 Name:

Gender:

Date of Birth:

Age:

Quran Reading Fluency – Circle as applicable:

Student 2 (Optional)

Student 2 Name:

Gender:

Date of Birth:

Age:

Quran Reading Fluency – Circle as applicable:

Student 3 (Optional)

Student 3 Name:

Gender:

Date of Birth:

Age:

Quran Reading Fluency – Circle as applicable:

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Parent/Guardian Details

Name:

Email:

Relationship to Student(s):

Mobile Phone:

Home Phone:

Home Address:

Area & Post Code:

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Alternative Emergency Contact Details

Name:

Relationship to Student(s):

Mobile Phone:

Home Phone:

Email Address:

Home Address:

Area & Post Code:

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Medical Information

Registered Doctor:

Surgery Address:

Surgery Phone:

Medical Condition

Do any of the children listed above have any medical condition(s) requiring attention such as asthma, diabetes, epilepsy, allergies etc. If yes, please list their names and condition(s).

Student 1 Condition(s):

Student 1 Medication:

Student 2 Condition(s):

Student 2 Medication:

Student 3 Condition(s):

Student 3 Medication:

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Authorisation for emergency medical treatment

I (parent/guardian) of the children mentioned overleaf, understand that in case of illness or injury, Dar ul-Isra will notify me or the person I have listed as the emergency contact. I authorise Dar ul-Isra to arrange for transportation of the sick child to a medical facility (if necessary) and to sign release as may be required, in order to obtain any medical or surgical treatment as required in the judgement of medical authorities at the facility.

General consent

I consent that my above mentioned children can attend the classes on a daily basis (week days from 5PM to 7PM). The Parent/Guardian would be responsible for the children outside of the class timings and outside the building premises.

Parent/Guardian Digital Signature (Type Full Name):