Registration - Al Hijra Islamic School

Parent Information

Father First Name *

Father Last Name *

Father Phone *

Father Email Address *

Mother First Name

Mother Last Name

Mother Phone

Email Address

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Country

Student Information

Child 1 Registration

First Name *

Last Name *

Date of Birth *

Student 9 digit health card # *

Child live with both parents *YesNo

Gender *MaleFemale

Last School Attended

Last Grade Completed

Child 2 Registration

First Name

Last Name

Date of Birth

Student 9 digit health card #

Child live with both parentsYesNo

GenderMaleFemale

Last School Attended

Last Grade Completed

Sibling attending Al-Hijra Islamic School *YesNo

Sibling Name *

Family Doctor Information

First Name *

Last Name *

Doctor's Phone *

Emergency Contact Information

First Name *

Last Name *

Child Medical History

Health conditions that apply to this student

Life Threatening Condition: *YesNo

Medical Information

Upload Health Card or Birth Certificate or Passport *

No file chosen

Parent Information

Student Information

Child 1 Registration

Child 2 Registration

Family Doctor Information

Emergency Contact Information

Child Medical History

Health conditions that apply to this student

ADDRESS

PHONE

EMAIL