Al-Azhar Islamic Academy Registration 2026-2027 Comprehensive Student Registration Form (2026–2027) 1STUDENT INFO2PARENT/GUARDIAN3EMERGENCY CONTACTS4AUTHORIZED PICKUP5HEALTH HISTORY6UPLOAD DOCS7SIGNATURE & FEES ✅ STUDENT INFORMATIONAcademic Year 2026-2027Student Name:(Required) First Middle Last Student Date of Birth(Required) Month Day Year KG: 5yrs by 9/1/2026 | TK: 4yrs by 9/1/2026Gender(Required) Male Female Grade Level Applying For:(Required)Pre-KindergartenTransitional KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th GradeCurrent Residence Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ✅ Financial Aid InformationDo you anticipate needing financial aid to support your child’s enrollment?(Required) Yes No ✅ Photo & Video Consent Dear Parents/Guardians, At Al-Azhar Islamic Academy, we value showcasing our students’ achievements and school activities through photos and videos. These may be shared on our school website, newsletters, or other official school publications. Please review the consent options below and indicate your preference:(Required) Consent to allow Al-Azhar Islamic Academy to take photos/videos of my child and use them for school-related purposes, including the school website, newsletters, and other official publications. Do Not Consent to allow Al-Azhar Academy to take photos/videos of my child for any school-related purposes. Parent/Guardian Primary Email(Required) This email will serve as the main point of contact and will receive all official correspondence, including payment confirmations and school notifications. ✅ PARENT / LEGAL GUARDIANMother/Guardian Full Name(Required)Mother Phone(Required)Mother Email(Required) Please check the box that closely pertains to you:(Required) Not a high school graduate. High school graduate. Some college (2 or 4 yr College or University). Graduate school/Post graduate training. Declines to state or unknown graduate. Father/Guardian Full Name(Required)Father Phone(Required)Father Email(Required) Please check the box that closely pertains to you:(Required) Not a high school graduate. High school graduate. Some college (2 or 4 yr College or University). Graduate school/Post graduate training. Declines to state or unknown graduate. ✅ EMERGENCY CONTACTSEmergency Contact #1:Full Name of Emergency Contact:(Required)Relationship to Student:(Required)Primary Phone Number:(Required)Secondary Phone Number:Emergency Contact #2:Full Name of Emergency Contact:Relationship to Student:Primary Phone Number:Secondary Phone Number:Family Doctor:Full Name of Family Doctor:Phone Number:Consent(Required) I certify that the above information is true and accurate. I authorize the school to contact the listed persons in case of emergency, and I understand it is my responsibility to update the school if any information changes. ✅ AUTHORIZED PICK-UP & LEGAL ORDERSNO ONE WILL BE PERMITTED TO PICK UP YOUR CHILD IF THEIR NAME IS NOT LISTED BELOW. ALL PERSONS MUST HAVE AND SHOW THEIR PICTURE ID. MAKE SURE YOU LIST ALL ADULTS EVEN IF YOU RESIDE IN THE SAME HOUSEHOLD. Authorized Person #1:Full Name of Authorized Person:Relationship to Student:Primary Phone Number:Secondary Phone Number:Authorized Person #2:Full Name of Authorized Person:Relationship to Student:Primary Phone Number:Secondary Phone Number:Days/Times this person is authorized to pick up (optional):Example: Sunday–Thursday, 2:00 PM – 4:00 PMIs there any court orders restraining any person from this student? No Yes Name of Person and Details of Order(Required)Upload Copy of Court Order Drop files here or Select files Max. file size: 2 GB. Consent(Required) I hereby authorize the above-named individual(s) to pick up my child from school. I understand that the school will not release my child to anyone not listed on this form. I accept full responsibility for keeping this information up to date with the school administration. ✅ STUDENT HEALTH HISTORYDoes your child have any health issues?(Required) My child does not have any health issues at this time. Yes, my child has health issues. Does your child take medication on a routine basis?(Required) Yes No Medication Name(Required)Does your child take any medication during school hours?(Required) Yes No Medication Name (Taken During School Hours)(Required)Medical Conditions / Concerns(Required) Asthma Seizures Physical Limitations Special Equipment Needed Allergies (Bees, Foods, Meds) Lactose Intolerance Heart/Cardiac Condition Diabetes Other Conditions Type of seizure(Required)Date of seizure(Required) MM slash DD slash YYYY Currently takes medication for seizures:(Required) Yes No Please provide details of any physical limitations(Required)Please describe any physical limitations your child may haveSpecial Equipment needed at home(Required)Special Equipment needed at school(Required)Please provide details about your allergies (e.g., type of food, medication, reaction, severity, etc.)(Required)“Please describe your heart or cardiac condition, including diagnosis, medications, restrictions, or precautions.”(Required)If applicable, please provide details of any other medical conditions, treatments, or precautions:(Required)Diabetes Type:(Required) Type 1 Type 2 Has your child been hospitalized for diabetes?(Required) Yes No Can your child monitor his/her blood glucose level independently?(Required) Yes No Can your child recognize symptoms of high or low blood glucose levels?(Required) Yes No If yes, what are the symptoms?(Required)Has Glucagon ever been given to your child?(Required) Yes No If yes, last given on (Glucagon):(Required)Is your child currently under a doctor’s care for any of the above(Required) Yes No Doctor’s Name(Required)Doctor’s Phone(Required)Doctor’s Address(Required)health_info_consent(Required) I hereby give permission to share information pertaining to the health of my child with school staff who need to know. ✅ UPLOAD REQUIRED DOCSUpload Required Registration DocumentsBirth Certificate Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 200 MB. Immunization Record Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 200 MB. Copy of Parent ID Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 200 MB. Current School Records Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 200 MB. ✅ SIGNATUREParent/Guardian Signature(Required)My signature certifies that all information provided on this form is accurate. I understand that changes in address, telephone numbers, and/or emergency information must be reported to the school for the safety of my child. ✅ REGISTRATION FEESPayment Information(Required) New Student (Requires $100 Fee) – Pay Online. New Student (Requires $100 Fee) – Pay by Cash/Check. Returning Student (No Fee). ✅ Application Fee – For New Students (Non-Refundable) Price: Pay Online.(Required)
