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Admission Form

This document contains a student information form for Darul-Uloom Al-Madania Inc., a religious educational institution located in Buffalo, NY. The form requests information such as the student's name, address, citizenship status, date of birth, education history, and emergency contact. It also collects similar information for the student's parent or guardian. The student is applying for admission to either the Hifz (Quran memorization) class for boys or the Alim/Alimah (religious studies) class.

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sarah_khokharicecrea
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365 views1 page

Admission Form

This document contains a student information form for Darul-Uloom Al-Madania Inc., a religious educational institution located in Buffalo, NY. The form requests information such as the student's name, address, citizenship status, date of birth, education history, and emergency contact. It also collects similar information for the student's parent or guardian. The student is applying for admission to either the Hifz (Quran memorization) class for boys or the Alim/Alimah (religious studies) class.

Uploaded by

sarah_khokharicecrea
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Darul-Uloom Al-Madania Inc.

182 Sobieski Street, Buffalo, NY 14212, U.S.A.


Tel: (716) 892-2606, (716) 895-3318; Fax: (716) 892-6621 www.madania.org

DATE:

_______________

STUDENT INFORMATION
Full Name __________________________________________________________________________________
(First Name)

(Middle Name)

(Last Name)

Address ____________________________________________________________________________________
(Street)

(City)

Tel. Number: HOME _____________________

(State)

WORK

(Zip Code)

(Country)

____________________ CELL __________________

Citizenship ___________ Status in US _________ Length of stay in US____________ DOB ______________


Place of Birth _____________________________ Gender: M [ ] F [ ] Social Security # ________________
(City)

(Country)

EDUCATION
Present Religious Education:
Name of Institute Attended ____________________________________________________________________
Address ____________________________________________________________________________________
( Street)

(City)

(State)

(Zip Code)

(Country)

Tel. Number: __________________ Names of languages you studied/know:_____________________________


Attended Date From: ____________ To: ______________ Reason for Leaving ___________________________
Number of times the Nazira has been repeated __________

How much Quran memorized _________________

Present Secular Education:


Name of School/College Last Attended ___________________________________________________________
Address ____________________________________________________________________________________
(Street)

(City)

(State)

(Zip Code)

(Country)

Tel. Number: _________________ Dates: From _____________ To____________ Grade Attained _________
ADMISSION APPLIED FOR:
CHECK ONE ONLY:

Hifz Class [ ]

(Boys Only)

Alim/Alimah Class [ ]

PARENT/GUARDIANS INFORMATION
Full Name __________________________________________________________________________________
Address ____________________________________________________________________________________
(Street)

(City)

Tel. Number: HOME ___________________


Citizenship ____________

WORK

(State)

(Zip Code)

(Country)

___________________ CELL ______________________

Occupation _______________ Email ____________________________________

Place of Birth _____________________________________


(City)

Social Security # __________________________

(Country)

EMERGENCY CONTACT
Name ______________________________________________

Tel. Number __________________________

Address ____________________________________________________________________________________
(Street)

Relation to Student: ____________________

_____________________________
Signature of Student

(City)

(State)

(Zip Code)

(Country)

Email ______________________________________________

_____________________________
Signature of Parent/Guardian

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